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A 


SYSTEM  UF  GYNECOLOrxY. 


BY  AMERICAN  AUTHORS. 


EDITED   BY 

MATTHEW   D.  MAXX,  A.M.,  M.  D., 

Professor  of  Obstetrics  and  Gynecology  in  the  Medical  Departjient  of 
THE  University  of  Buffalo,  X.  Y. 


VOLUME   I. 


ILLUSTRATED  WITH  THREE  COLORED    PLATES  AND   TWO    HUNDRED 
AND  ONE  ENGRAVINGS  ON  WOOD. 


PHILADELPHIA : 

LEA    BROTHEPvJS    &    CO 


Entered  nccording  to  Act  of  Congress,  in  the  year  1887,  by 

LEA    BROTHERS    &    CO., 

in   the  Office  ot  the  Librarian  of  Congress  at  Washington.     All  rights  reserved. 


WnsTcoTT  &  Thomson,  William  J.  Dornan, 

Slereoiypers  and  Electrotypers,  Philada.  Printer,  Philada. 


PREFACE. 


Ix  all  departments  of  science  the  largest  results  are  to  be  obtained 
l>y  division  of  labor  and  combination  of  effort.  In  Medicine  this  is 
especially  true,  and  the  favor  with  which  the  profession  has  greeted 
recent  systems  of  Practice  and  Surgery,  concentrating  the  experience 
of  leading  men  on  each  subject,  shows  that  such  a  plan  of  composition 
is  more  satisfactory  than  the  effort  of  a  single  author  to  treat  exhaust- 
ively all  the  details  of  an  extensive  branch  of  practice.  By  a  careful 
preliminary  survey  of  the  ground,  and  the  assignment  of  each  sub- 
division to  a  practitioner  who  has  made  it  the  special  subject  of  study, 
omissions  are  avoided,  every  article  is  authoritative,  and  each  is 
treated  with  the  fuhiess  to  which  its  importance  entitles  it. 

Gynecology  has  now  grown  to  an  extent  which  requires  for  its 
thorough  treatment  this  co-operation  of  representative  men ;  and  it  is 
eminently  fitting  that  the  science  which  is  in  so  great  a  degree  of 
American  origin  should  be  thus  presented  by  American  practitioners. 
The  labors  of  the  Editor  have  been  principally  confined  to  the  selec- 
tion of  contributors  and  the  assignment  of  subjects,  and  it  is  with  no 
little  pride  that  he  refers  to  the  list  of  eminent  gentlemen  whose  co- 
operation has  secured  in  advance  the  position  which  the  Avork  must 
assume  as  the  leading  authority-  on  its  subject.  The  common  effort 
has  been  to  render  each  article  not  only  full  and  complete,  but  thor- 
oughly practical,  special  regard  being  paid  to  the  needs  of  the  general 
practitioner  as  well  as  to  those  of  the  specialist.  The  responsibilit}-^ 
for  the  views  presented  rests  wholly  "^ith  the  contributors ;  and  if 
there  are  occasionally  found  more  or  less  overlapping  and  some  differ- 
ences of  opinion  on  certain  disputed  points,  this  carries  with  it  the  cor- 


iv  PREFACE. 

relative  advantage  of  enabling  readers  to  compare  different  views  and 
to  value  them  at  their  worth. 

In  conclusion,  the  Editor  would  express  his  thanks  to  the  contribu- 
tors for  the  courtesy  and  zeal  which  have  characterized  their  co-opera- 
tion, and  he  would  further  acknowledge  his  indebtedness  to  his  prede- 
cessors, Drs.  Charles  S.  Ward  and  Henry  D.  Nicoll,  not  only  for  their 
preliminary  labors,  but  for  the  good-will  which  they  have  so  generously 
manifested. 


CONTRIBUTORS  TO  VOLUME  I. 


HENRY  C.  COE,  A.  I\I.,  M.  D.,  New  York  City, 

Pathologist  to  the  Woman's  Hospital  in  the  State  of  New  York;  Visiting^  Ob- 
sti'triciaii  to  the  lufant  Asylum;  Instructor  in  Gynecology  at  the  New  York 
Polvcliiiic. 


EMILIUS  C.  DUDLEY,  A.  B.,  M.  D.,  Chicago, 

Professor  of  Gynecology  in  the  Chicago  Medical  College ;  Gynecologist  to  Mercy 
Hospital  and  to  Cook  County  Hospital,  and  to  St.  Luke's  Hospital. 


HENRY  J.  GARRIGUES,  A.  M.,  M.  D.,  New  York  City, 

Professor  of  Practical  Obstetrics  at  the  New  York  Post-graduate  School  and  Hos- 
pital ;  Obstetric  Surgeon  to  the  New  York  Maternity  Hospital ;  Obstetrician 
to  the  New  York  lufaut  Asylum  ;  Gynecologist  to  the  German  Hospital. 


EGBERT  H.  GRANDIN,  A.B.,  M.  D.,  New  York  City, 

Instructor  in  Gynecology  at  the  New  York  Polyclinic  ;  Obstetric  Surgeon  to  the 
New  York  Maternity  Hospital. 


A.  REEYES  JACKSON,  A.  M.,  M.  D.,  Chicago, 

Professor  of  Gynecology  in  the  College  of  Physicians  and  Surgeons  of  Chicago, 
and  the  Chicago  Policlinic;  Hon.  Fellow  Boston  Gynecological  and  Detroit 
Gynecological  Societies;  Fellow  of  the  American  Gynecological,  British  Gyn- 
ecological, and  Chicago  Gynecological  Societies;  Consulting  Surgeon  of  the  Dis- 
pensary of  the  Women's  Christian  Association  ;  Chief  of  the  Gynecological 
Department  of  the  West  Side  Free  Dispensary  ;  formerly  Surgeon-iu-chief 
of  the  Woman's  Hospital  of  the  State  of  Illinois. 

EDWARD  W.  JENKS,  M.  D.,  LL.D.,  Detroit, 

Fellow  of  the  American  Gynecological  Society  and  the  Obstetrical  Society  of  Lon- 
don; Corresponding  Fellow  of  the  Boston  Gynecological  Society;  Honorary 
Member  of  the  Cincinnati  Obstetrical  Society  and  the  State  Medical  Associa- 
tions of  Maine,  Ohio,  Michigan,  etc. ;  formerly  President  and  Prnfessor  of 
Gynecology  and  Obstetrics  in  Detroit  Medical  College,  and  late  Professor  of 
Gynecology  in  Chicago  Medical  College. 


VI  •  CONTRIBUTORS. 

MATTHEW  D.  MANN,  A.  M.,  M.  D.,  Buffalo, 

Professor  of  Obstetrics  and  Gynecology  in  the  Medical  Department  of  the  Uni- 
versity of  Buffalo ;  Gynecologist  to  the  Buffalo  General  Hospital. 

RICHARD  B.  MAURY,  M.  D.,  Memphis, 

Professor  of  Gynecology  in  the  Memphis  Hospital  Medical  College. 

CHAUNCEY  D.  PALMER,  M.  D.,  Cincinnati, 

Professor  of  Obstetrics  and  the  Medical  and  Surgical  Diseases  of  Women  and  Clin- 
ical Gynecology  in  the  Medical  College  of  Ohio  ;  Gynecologist  to  the  Cincinnati 
Hospital. 

THADDEUS  A.  REAMY,  A.  M.,  M.  D.,  Cincinnati, 

Professor  of  Clinical  Gynecology  in  the  Medical  College  of  Ohio ;  Gynecologist 
to  the  Good  Samaritan  Hospital;  Obstetrician  and  Gynecologist  to  the  Cin- 
cinnati Hospital. 

ALPHONSO  D.  ROCKWELL,  M.  D.,  New  York  City, 

Formerly  Electro-therapeutist  to  the  Woman's  Hospital  in  the  State  of  New 
York ;  Member  of  the  American  Neurological  Association. 

ALEXANDER  J.  C.  SKENE,  M.D.,  Brooklyn, 

Professor  of  the  Medical  and  Surgical  Diseases  of  Women  in  the  Long  Island 
College  Hospital,  Brooklyn,  N.  Y. 

ELY  VAN  DE  WARKER,  M.  D.,  Syracuse,  N.  Y., 

Surgeon  to  the  Central  New  York  Hospital  for  Women;  Fellow  of  the  American 
Gynecological  Society  ;  Fellow  of  the  New  York  State  Medical  Association. 

W.  GILL  WYLIE,  M.  D.,  New  York  City, 

Professor  of  Gynecology  in  the  New  York  Polyclinic;  Gynecologist  to  Bellevue 
Hospital ;  Surgeon  to  St.  Elizabeth's  Hospital ;  Member  of  American  and  Brit- 
ish Gynecological  Societies ;  Fellow  of  New  York  Academy  of  Medicine. 


CONTENTS   OF  VOLUME   I. 


PAGE 

HISTORICAL   SKETCH   OF  AMERICAN  GYNECOLOGY.     By  Edward 

W.  Jenks,  M.  D.,  LL.D 17 

THE   DEVELOPMENT   OF   THE  FEMALE  GENITALS.     By  Henry  J. 

Garrigues,  a.  M.,  M.  D 68 

THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.      By  Hexrt  C. 

CoE,  M.  D.,  M.  R.  C.  S 95 

MALFORMATIONS    OF    THE    FEMALE    GENITALS.       By  Hexry  J. 

Garrigues.  A.  M.,  M.  D 235 

GYNECOLOGICAL   DIAGNOSIS.     By  Egbert  H.  Graxdin,  A.  B.,  M.  D.  283 

GENERAL  CONSIDERATION  OF  GYNECOLOGICAL  SURGERY.      By 

E.  C.  Dl-dlet,  a.  B.,  M.  D 328 

GENERAL  THERAPEUTICS.     By  Alexaxder  J.  C.  Skexe,  M.  D.    .    .    .    363 

ELECTRICITY  IN  GYNECOLOGY.     By  Alphoxso  D.  Rockwell,  A.  M., 

M.  D 383 

MENSTRUATION,  AND  ITS  DISORDERS.     By  W.  Gill  Wylie,  ]M.  D.  .    408 

STERILITY.     By  A.  Reeves  Jacksox,  A.  M..  M.  D 441 

DISEASES  OF  THE  VULVA.      By  Matthew  D.  Maxx,  A.  M.,  M.  D.    .    .    477 

THE   INFLAMMATORY   AFFECTIONS   OF   THE    UTERUS.     By  C.  D. 

Palmer,  M.  D 541 

SUBINVOLUTION    OF   THE   VAGINA   AND   UTERUS.      By  Thaddecs 

A.  Reamy,  A.m.,  M.D 637 

PERIUTERINE    INFLAMMATION.     By  Richard  B.  Maury,  M.  D.  .    .    .    675 

PELVIC    H.EMATOCELE    AND    H.EMATOMATA.      By    Ely    Vax    de 

Warker,  M.  D 735 

vii 


LIST  OF  WOOD  ENGRAVINGS. 


Flo.  PAGE 

1.  Section  ol'  Fftftal  llalibit 69 

2.  Section  of  Posterior  Part  of  Foetal  I\al)bit 69 

3  and  4.     Skene's  Urethral  Glands 70 

5.  Cross-section  of  Urethra 71 

6.  Cross-section  of  Urethra,  sliowing  Skene's  Glands I'l 

7.  Skene's  Gland  laid  ojjen 72 

8.  Fo?tus  of  Thirty-five  Days 73 

9.  Genital  Organs  of  Embryo  Cattle 74 

10.  Internal  (xenitals  of  Female  Human  Foetus 75 

11.  Internal  Genitals  of  Male  liuman  Foetus 75 

12.  Cross-section  of  Foetal  Ovary 76 

13.  Cross-section  of  Ovary  of  Bitch  of  Six  Months 77 

14.  Cross  section  of  Ovary  of  Human  Foetus 78 

15.  Cross-section  through  Ovarian  Region  of  Foetus 80 

16.  Ovary  of  Human  Fffitus  at  Tenth  Week 81 

17.  Ovary  of  Human  Foetus  at  Tenth  Week  (magnified) 81 

18.  Formation  of  Ova 81 

19.  Permanent  Epithelium  of  Ovary 81 

20.  Ovary  in  Thirty-sixth  Week , 82 

21.  Cross-section  of  Ovary  at  Birth 82 

22.  Graafian  Follicles  at  Birth 82 

23.  Graafian  Follicle  Seven  Months  Old 83 

24.  Human  Ovum 84 

25.  Primordial  Ova 85 

26.  Wolffian  Body  of  Babbit 86 

27.  Section  of  Genital  Cord 88 

28  and  29.     Ovaries,  Tubes,  and  Uterus  at  Tenth  Week 88 

30.  Visceraat  Fifth  Month 89 

31  and  .32.     Urogenital  Sinus 89 

33.  Urogenital  Sinus  at  Different  Ages 90 

34  and  35.     External  Genitals  in  Foetus 93 

36.  Mesial  Section  of  External  Genitals     .    .        96 

37.  External  Genitals 97 

38.  Veins  of  Vulva  and  Perineum 103 

39.  Veins  of  Vagina  and  Vulva 105 

40.  Venous  Plexuses  of  Clitoris 106 

41.  Perineal  Septum 107 

42.  Arteries  and  Veins  of  Vagina  and  Uterus 122 

43  and  44.     Sections  of  the  Vaginal  Wall 123 

45.  Section  of  Mucous  Membrane  of  Uterus 136 

46.  Interior  of  Cervix 137 

47.  Utricular  Glands 140 

48.  Section  of  Decidua - 141 


X  LIST  OF   WOOD  ENGRAVINGS. 

Fig.  Page 

49.  Ovarian  and  Uterine  Arteries 144 

50.  Nerves  of  the  Uterus      145 

51.  Transverse  Section  of  the  Body  at  Brim  of  Ti'ue  Pelvis 146 

52.  Horizontal  Section,  showing  Uterus  and  Ligaments 15S 

53.  Pubic  Termination  of  Round  Ligaments 159 

54.  Cross-section  of  Tubes ,   .  163 

55.  Cross-section  of  Tubes,  showing  Lymph-spaces 165 

56.  Section  of  Ovary 171 

57.  Section  of  Ovary  (low  power) 173 

58.  Section  of  Ovary  in  Infant 174 

59.  Frozen  Section  of  Pelvis 184 

60.  Section  of  Vesico- vaginal  Septum 187 

61.  Muscular  Fibres  of  Bladder 190 

62.  Epithelium  of  Bladder -190 

63.  Relation  of  Ureters 193 

64.  Surgical  Relations  of  Uretei'S      195 

65.  Rectum  Inflated 198 

66.  Section  of  End  of  Rectum 200 

67.  Diagram  of  Pelvic  Peritoneum ^    .    .    .  205 

68.  Cross-section  of  Pelvis 206 

69.  Diagram  of  Broad  Ligaments 208 

70.  Diagram  of  Broad  Ligaments 209 

71.  Reflections  and  Pouches  of  Pelvic  Peritoneum .  211 

72.  Mesial  Section  of  Pelvis 217 

73.  Model  of  Uterine  Supports 221 

74.  .Fascia  of  Pelvic  Floor 223 

75.  Muscles  of  Pelvic  Floor 224 

76.  Section  of  Pelvis  through  Vagina 225 

77.  Attachments  of  Muscular  Floor  of  Pelvis 226 

78.  Perineal  Septum 231 

79.  Muscular  Floor  of  Pelvis  in  Labor 233 

80.  Rudimentary  Uterus  (Nega) 240 

81.  Rudimentary  LTterus  (Langenbeck) 241 

82.  Uterus  Bipartitus 242 

83.  Bipartite  Uterus  and  Ovaries 244 

84.  Uterus  Didelphys 245 

85.  Uterus  Unicornis 246 

86.  Uterus  Bicornis  Duplex 247 

87.  Uterus  Bicornis  Duplex 248 

88.  Uterus  Bicornis  Unicollis      249 

89.  Uterus  Arcuatus 249 

90.  Uterus  Septus  Duplex 250 

91.  Uterus  Septus  Uniforis 251 

92  and  93.     Double  Vagina 251 

94.  Infantile  Uterus ' 254 

95.  Infantile  Uterus,  coronal  section 255 

96.  Uterus  Incudiformis 256 

97.  Persistent  Cloaca 261 

98.  Persistent  Sinus  Urogenitalis 261 

99.  The  Hymen      .    .    ." 262 

100.  Hypospadias 265 

101.  Epispadias 266 

102.  Lateral  Hermaphrodism 271 

103.  Internal  Genitals  of  Fig.  102 271 

104.  Internal  Genitals,  left  side 272 


LIST  OF   WOOD   EXnnAVrXa.S.  XI 

Fi<i-  I'.\(;k 

lOo  and  lOG.     rienitals  of  Carl  llnlimami 274 

1U7  and  108.     Carl  llolunaini 'j7o 

109  and  110.     .Siipjiosed  Section  of  Iloliriiinin          Ii7,j 

111.     Chadwick's  Table 2!l4 

11  "J.     Chadwick's  Table -J'.j.j 

11.;.     Dagget's  Table 2'.J-') 

114.     Dagget's  Table 290 

1  lo.     .Simpson's  Somid 30;i 

IK).     Fergiisson's  Speculum 305 

117.     Brewer's  S|ieculuni      3(j.O 

lis.     Null's  Speculum 30(j 

119.  Left  Lateral  Position      309 

120.  Sims's  Depressor 311 

121.  Sims's  Speculum      311 

122.  Hunter- Erich  Speculum 311 

123.  Thomas-Mann  Speculum 312 

124.  Munde's  Speculum      313 

125.  Emmet's  Tenaculum 314 

126.  Sims's  Tenaculum 314 

127.  Emmets  Probe 315 

128.  Skene's  Endoscope 317 

129.  Kelsey's  Eectal  Speculum 318 

130.  GoodeU's  Dilators 319 

131.  Palmer's  Dilators 320 

132.  Hanks's  Dilator 320 

133.  Emmet's  Water-Dilator 321 

134.  Molesworth's  Dilator 322 

13o.     Tupelo  Tents 322 

130.     Thomas's  Dull  Curette • 324 

137.  Dieulafoy's  Aspirator 320 

138.  Emmet's  Aspirator 320 

139.  Simon's  Speculum 342 

140.  Emmet's  Double  Tenaculum  Forceps 343 

141.  Emmet's  Double  Tenaculum  Forceps 343 

142.  Sims's  Sponge-holder      ,343 

143.  Emmet's  Scissors 344 

144.  Emmet's  Scissors,  curved 344 

145.  Emmet's  Scissors,  strongly-curved 344 

146.  Emmet's  Ball-and-Socket  Knife 345 

147.  Uterine  Tenaculum ,345 

148.  Method  of  Denudation 346 

149.  Needles 347 

150.  Emmet's  Needle-Forceps 348 

151.  Needles  Threaded  with  Loop ,348 

152.  Counter-pressure  to  Needle 34y 

153.  Counter-pressure  to  Hook 349 

154.  Vulsellum  Forceps 349 

155.  Suture  in  Position 350 

156.  All  Sutures  in  Position      350 

157.  Slipknot  on  Suture 351 

158.  Twisting  with  a  Tenaculum 351 

159.  Shouldering  a  Suture 351 

160.  Twisting  Forceps 352 

161.  Sims's  Shield 352 

162.  Twisting  a  Suture 352 


Xll  LIST  OF   WOOD  EXGRAVISOS. 

Fig.  page 

163.  Bending  Twisted  Wire 3,52 

164.  Removing  a  Silver  Suture 3.53 

165.  Sponge  Tent 355 

166.  Laminaria  Tent 356 

167.  Introducing  a  Tent 357 

168.  Fritsch's  Dilators • 358 

169.  Schultze's  Dilators 358 

170.  Xott's  Dilators .  358 

171.  Thomas's  Dull  Wire  Curettes 360 

172.  Simon's  Sharp  Spoon      - 361 

173.  Sims's  Curette 418 

174.  Sims's  Dilator 427 

175.  Wylie's  Cervical  Protector 428 

176.  Wylie's  Intra-uterine  Drainage-tube 429 

176j.  Veins  of  Vulva 479 

177.  Anterior  Vaginal  Hernia 484 

178.  Lupus  Prominens 522 

179.  Palmers  Intra-uterine  Canula 546 

180.  Davidson's  Syringe 556 

181.  Vaginal  Irrigator 556 

182.  Peaslee's  Dilators 559 

183.  Palmei-'s  Dilator 560 

184.  Conoid  Cervix 560 

185.  Dilated  Canal 561 

186.  Hard-rubber  Probe  Applicator 564 

187.  Applicator .577 

188.  Self-retaining  Tenaculum 577 

189.  Palmer's  Intra-uterine  Medicator 579 

190.  Applicator  Syringe 580 

191.  Sims's  Applicator 580 

192.  Applicator  Syringe 581 

193.  Eecamier's  Curette 596 

194.  Thomas's  Curette 596 

195.  Sims's  Curette 597 

196.  Simon's  Spoon 597 

197.  Emmet's  Curette  Forceps 597 

198.  Buttle's  Spear 613 

199.  Knife  for  Intra-uterine  Scarification 614 

200.  Eetlections  of  Pelvic  Peritoneum 683 

201.  Sagittal  Section  of  Pelvis 685 


Plate    I. 

Lupus  Hypertrophicus 'Duncan  I,  more  properly  Fibroma  Diffiisum    .    .    .  527 

Plate   II. 

1.  Erosion  of  the  Cervix  (iVreigsi 5-50 

2.  Follicular  Erosion  with  Slight  Laceration  (Munde) 550 

3.  Granular  Degeneration  of  an  Elongated  Cervix  (Meigs) 550 

4.  Erosion,  Cystic  Enlargement,  Catarrh  of  Cervix  (Meigs) 550 

Plate    III. 

1.  Chronic  Hyperemia.  Catarrh,  and  Enlargement  of  the  Cervix  CMeigs)  .    .  601 

2.  Chronic  Metritis  and  Endometritis  '  MeigsJ 601 


HISTORICAL  SKETCH  OF  AMERICAN 
GYNECOLOGY. 

By  EDWARD  W.  JENKS,  M.D.,  LL.D., 

DeTKOIT,   MiCHKtAN. 


As  in  the  case  of  most  nations,  so  in  that  of  medicine,  of  whose  his- 
tory it  forms  a  part,  the  earliest  dawnings  are  traceable  to  tradition, 
and  in  many  instances  the  historian  is  obliged  to  go  back  of  anthen- 
ticated  records  for  the  material  with  which  to  construct  the  foundation 
of  his  story.  In  writing  a  history  of  American  medicine  in  any  of  its 
divisions  this  difficulty  does  not,  however,  present  itself,  for,  like  the 
American  people  itself,  it  arises  from  a  foundation  laid  in  centuries  of 
Transatlantic  life.  While,  therefore,  in  essaying  a  history  of  the  achieve- 
ments of  American  surgeons  in  the  treatment  of  diseases  peculiar  to 
women  I  am  not  obliged  to  analyze  aught  which  is  of  doubtfiil  authen- 
ticity as  a  basis  for  a  starting-point,  it  has  seemed  to  me  that  a  brief 
resiune  of  the  historical  facts  which  form  the  foundation  of  gynecol- 
ogy as  it  exists  in  America  to-day  will  greatly  assist  to  the  clearest  con- 
ception of  the  superstructure.  The  explorations  of  antiquarians  of  later 
years  into  that  which  has  been  hidden  by  the  debris  of  centm-ies  has, 
moreover,  unearthed  so  many  of  the  prototypes  of  modern  discoveries 
that  a  consideration  of  the  latter  could  scarcely  be  held  to  be  comj)lete 
without  a  reference  to  their  predecessors  in  the  remote  ages. 

Gynecology  is  singularly  rich  in  illustrations  of  the  belief  that  prog- 
ress is  in  the  direction  of  a  circle  rather  than  in  that  of  a  straight 
line — "  that  which  hath  been  is,  and  that  which  is  shall  be  ;"  and  manv 
of  the  brilliant  discoveries  with  which  it  has  been  enriched  in  modern 
times,  and  even  in  America,  were  really  but  rediscoveries  of  discoveries 
which  the  mutations  of  time  have  effiiced  from  the  memories  and  the 
records  of  men. 

AYhile  the  current  of  gynecology  as  it  has  flowed  down  to  us  in  an 
ever-widening  stream  from  the  past  is  traceable  with  definite  clearness 
onlv  to  the  Greeks,  there  is  evidence  that  it  did  not  have  its  orig-in 
among  that  remarkable  people,  but  that  it  trickled  in  rivulets,  too  small 
for  the  attention  of  the  great  majority  of  explorers,  from  the  people  living 
on  the  Xile.  That  the  stream  was  clearly  recognized  in  the  days  of 
Homer  and  Herodotus  is  attested  in  the  writings  of  those  immortal 

Vol.  L.—2  17 


18  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

Greeks,  who  wrote  in  terms  of  the  highest  admiration  of  the  skill  and 
the  learning  of  the  physicians  of  Egypt. 

The  physicians  under  the  Ptolemies  were  required  to  regulate  their 
practice  according  to  certain  books,  one  of  which  was  devoted  to  diseases 
peculiar  to  women.  These  books  were  held  as  sacred,  and  their  authority 
was  thus  unquestionable.  Doubtless,  there  existed  among  a  people,  evi- 
dences of  whose  greatness  have  of  more  recent  years  been  so  abundantly 
revealed,  other  works  on  this  subject,  but  Saracen  fanaticism  in  the 
destruction  of  the  Alexandrian  Library  with  its  600,000  volumes  blotted 
out  the  story  of  what  Egypt  once  was,  and  has  left  us  only  to  conjecture. 
When  the  difference  in  the  language  and  political  complexion  of  Greece 
and  Egypt  is  considered  in  connection  with  the  necessarily  limited  in- 
tercommunication of  the  two  peoples,  it  is  but  reasonable  to  suppose 
that  comparatively  little  of  the  learning  of  the  older  civilization  found 
its  way  to  Greece,  and  that  such  inkling  as  we  have  received  through 
the  Greeks  of  the  status  of  Egyptian  medicine  is  very  meagre  when 
compared  with  the  actual  advancement  which  obtained. 

The  destruction  of  the  Alexandrian  Library  has  left  the  writings 
of  Hippocrates,  written  about  450  B.  c,  the  oldest  extant  containing 
anything  like  a  systematic  consideration  of  the  diseases  of  women. 
Moses,  who  was  versed  in  "  all  the  learning  of  the  Egyptians,"  shows 
a  remarkable  familiarity  with  the  sexual  peculiarities  of  women,  but 
he  treats  of  them  in  their  physiology,  and  interests  himself  in  the 
hygiene  of  the  genitalia  rather  than  in  their  diseases. 

In  the  lano-uaoe  of  Adams,  the  learned  commentator  on  the  works 
of  Hippocrates,  "  these  works  furnish  the  most  indubitable  proofs  that 
the  obstetric  art  had  been  cultivated  with  most  extraordinary  ability  at 
an  early  period."  Li  regard  to  gynecology  proper,  these  works  are, 
however,  disappointing  to  him  who  has  been  led  to  admire  and  revere 
the  philosopher  of  Cos  through  a  study  of  his  works  on  general  med- 
icine. Hippocrates  advised  the  use  of  aromatic  ftimigations  in  amenor- 
rhoea,  which  fumigations  he  also  recommended  as  a  test  of  fertility  in 
the  female.  The  woman  who  did  not  conceive  was  T\a'apped  in  blankets 
and  fumigated  from  beneath  ;  if  the  scent  passed  through  her  body  to 
the  nostrils  and  mouth,  then  it  was  known  that  she  was  not  unfruitftil ! 
"While  he  recognized  a  causative  relation  between  the  uterus  and  hys- 
teria, he  maintained  that  the  movement  of  the  womb  toward  the  head 
caused  pain  under  the  eyes  and  nose,  with  abundant  and  frothy  saliva ; 
if  it  moved  toward  the  hypochondrium,  it  caused  vomiting  of  an  acrid, 
burning  matter ;  if  it  moved  toward  the  liver,  it  caused  loss  of  speech, 
clenching  of  the  teeth,  and  a  livid  skin.  The  remedies  for  these  various 
hysterical  symptoms  were  as  ludicrous  as  their  etiology.  Nulliparae  were 
held  to  be  more  subject  to  menstrual  disorders  than  women  who  had 
borne  children,  for  the  veins  of  the  woman  ^^^ho  has  given  birth  to  a 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  19 

child  canv  oil"  the  iiiciistriial  discharge  more  readily,  because  the  lochial 
discharge  improves  the  eireidation.  The  views  of  the  "  Father  of 
Medicine"  on  the  treatment  of  uterine  hemorrhage  were,  however, 
more  sensible.  Wv  discover,  indeed,  in  them  some  of  the  fundamental 
])rineiples  of  the  advanced  metiiods  of  our  own  day.  His  knowledge 
of  the  relation  of  sym[)athy  between  the  uterus  and  the  mannnte  is 
api)arent  in  his  instruction  to  apjdy  a  large  cupping  instrument  to  the 
breast  as  a  means  of  staying  uterine  hemorrhage.  His  descriptiiju  of 
leucorrh(oa  and  the  fre(iuent  attendant  systemic  condition  is  graphic, 
although  his  therapy  of  the  aif'ection  is  crude.  The  prolapsed  uterus, 
he  savs,  "  hangs  down  like  a  scrotum."  It  should  be  well  washed 
with  iLstringcnt  lotions  and  restored  to  its  place,  when  the  woman  must 
be  placed  on  her  back  with  her  legs  crossed  and  tied  together.  That 
Hippocrates  recognized  the  fact  that  a  molar  pregnancy  occurring  in  an 
unmarried  woman  im})eached  her  virtue  is  evident  from  his  statement 
that  moles  are  caused  by  a  superabundance  of  menstrual  blood,  together 
with  a  bad  condition  of  the  semen.  He  gives  a  clear  differential  diag- 
nosis between  molar  and  true  pregnancy.  His  description  of  cancer 
of  the  uterus  is  clear,  and  his  gloomy  prognosis  in  such  cases  has  not 
been  much  1)riglitened  by  the  advances  made  since  his  day.  We  recog- 
nize in  the  "  pliimus  "  of  his  day  the  modern  stenosis  of  the  os.  He 
recommends  an  application  containing  verdigris  for  its  relief.  His 
remarks  on  atresia  of  the  vagina  and  uterus  command  attention : 
"  Sometimes  the  vagina  becomes  obstructed  after  parturition.  I  have 
seen  a  case  where  the  parts  were  torn  during  delivery,  causing  excoria- 
tions, after  which  the  parts  became  seriously  inflamed,  so  that  the  lips 
touched  and  became  united  as  in  wounds.  After  the  subsidence  of  the 
inflammation  the  lips,  which  had  reunited,  offered  an  obstacle  to  the  men- 
strual discharge,  preventing  its  free  exit.  It  is  necessary  in  such  a  case 
to  dress  the  lacerated  parts  and  cause  cicatrization,  but  it  is  also  neces- 
sary that  the  cicatrix  be  firm  and  complete,  while  it  is  very  difficult 
to  secure  this  result.  In  the  instance  of  which  I  speak  all  the  results 
took  place  which  occur  when  the  menses  are  suppressed  by  malforma- 
tion of  the  uterus,  but  the  principal  pain  was  felt  in  the  vagina,  which 
the  woman  found  to  be  occluded.  After  suitable  treatment  the  men- 
strual flow  was  re-established,  the  woman  recovered  her  health,  and 
afterward  bore  children.  If  the  case  had  been  neglected,  the  wound 
would  have  increased  in  size,  and  a  cancer  would  have  been  the  final 
result."  It  is  evident  that  the  subject  of  sterility  received  much  of 
his  attention,  and  his  views  concerning  the  causation  of  the  same  are 
interesting.  He  held  the  cause  to  be  one  or  several  of  the  following : 
"  1.  Because  the  os  uteri  is  turned  obliquely  from  the  passage  to  it. 
2.  Because  the  inside  of  the  uterus,  being  smooth,  either  naturally  or 
in  consequence  of  cicatrices  and  ulcers,  does  not  retain  the  semen. 


20  HISTORICAL  SKETCH   OF  AMERICAN   GYNECOLOGY. 

3.  When,  owing  to  the  suppression  of  the  menses,  any  obstruction 
takes  j)lace  in  the  os  uteri,  it  is  apt  to  prevent  impregnation.  4.  When 
impregnation  does  not  take  place,  the  veins  of  the  uterus  become  so 
engorged  with  blood  that  they  do  not  retain  the  semen ;  or,  on  the 
contrary,  the  same  effect  may  arise  from  profuse  menstruation,  whereby 
the  retentive  faculty  of  the  vessels  is  weakened  and  a  return  of  the 
menstrual  fluid  in  too  great  quantity  may  wash  away  the  ,semen.  5. 
Prolapsus  uteri,  by  rendering  the  mouth  of  the  uterus  hard  and  cal- 
lous, prevents  impregnation." 

Among  the  Romans  there  is  evidence  that  the  diseases  of  woman 
received  especial  attention.  Their  knowledge  was,  however,  mainly 
derived  from  Greece  and  Alexandria,  their  writings  revealing  none 
of  the  originality  of  thought  and  boldness  of  procedure  which  have 
always  marked  progress  in  this  division  of  medicine.  Celsus  was  a 
voluminous  writer,  but  it  is  to  be  regretted  that  so  much  of  such  parts 
of  his  works  as  treated  especially  of  the  diseases  of  women  have  been 
lost  as  to  leave  us  at  best  a  very  disjointed  reference  to  the  subject. 
Enough  has,  however,  been  preserved  of  his  ^vritings  and  of  those  of 
Galen  to  convince  us  that  as  early  as  the  first  century  of  the  Chris- 
tian era  the  speculum,  rediscovered  by  Recamier  in  1816,  was  not 
unknown ;  that  the  vaginal  touch  was  used  as  a  means  of  diagnosis ; 
and  that  ulceration  of  the  womb  and  leucorrhoea  in  its  several  vari- 
eties had  been  recognized.  In  the  excavations  of  Pompeii  and  Her- 
culaneum,  overwhelmed  with  lava  from  Mount  Vesuvius  A.  D.  79, 
and  remaining  buried  for  nearly  eighteen  hundred  years,  there  were 
found  among,  other  surgical  instruments,  two  specula,  such  as  were 
probably  in  common  use  at  the  time  of  the  catastrophe. 

Following  the  faint  glimmer  of  light  emitted  from  Rome,  we  have 
a  period  of  almost  absolute  darkness  extending  over  five  hundred 
years,  all  of  such  history  of  the  medicine  of  those  years  as  may 
have  been  written  having  at  last  become  extinct.  At  the  end  of 
this  period  we  find  at  work  in  the  library  at  Alexandria  one  iEtius, 
a  Greek,  whom  the  fame  of  that  wonderfiil  collection  had  probably 
attracted  from  his  native  land,  although  the  fact  that  he  refers  occa- 
sionally in  his  writings  to  cases  occurring  under  his  own  eye  gives 
color  to  the  belief  that,  besides  delving  in  the  accumulated  lore,  he 
also  engaged  in  the  practice  of  his  profession.  The  writings  of  ^tius, 
compilations  chiefly  from  the  Alexandrian  collection,  having  fortu- 
nately been  preserved,  we  are  permitted  to  know  through  them  some- 
thing of  the  status  of  medicine  in  Egypt  a  millennium  and  a  half  ago. 
A  study  of  these  writings  will  open  up  a  wonderful  revelation  to  those 
who  regard  gynecology  as  peculiarly  a  development  of  these  later 
times.  They  consist  of  four  books  (tetrabiblus),  each  of  which  is  in 
turn  subdivided  into  many  chapters.     The  fourth    discourse    of   the 


insTonrcAL  sKj'yrcir  of  AM^nrcAx  cysF.coLoaY.        21 

fonrtli  book,  containimj;  one  liiiiuli'cd  ami  twelve  (•lia|)t('rs  varvinsj:;  in 
loiiiitli  fVoni  a  few  lines  to  several  pai^cs,  is  [)riii('ij)ally  devoted  to 
obstetrics  ;uid  diseases  of  women.  In  it  the  nterns  and  the  ovaries, 
their  strnetnre  and  fnnetion,  are  described  with  a  de<i:ree  of  exactness 
which  both  disposes  of  the  assnraption  that  the  ancients  were  i<>;norant 
of  physioloiiv,  and  proves  that  they  possessed  instrnments  for  ocular 
examination  of  the  uterus  (their  dioptra)  and  sounds  for  determining 
its  size  in  the  living  subject.  The  description,  too,  which  is  given  of 
the  methods  in  vogue  for  preventing  tlie  legitimate  consequences  of 
sexual  congress  and  for  inducing  abortion  proves  that  the  nefarious 
practices  by  means  of  which  the  female  of  our  day  would  accomplish 
the  same  result  are  not  of  modern  origin.  Latero-version,  antever- 
sion,  and  retroversion  of  the  uterus,  and  various  methods  for  the  relief 
of  these  displacements,  are  discussed,  and  mention  is  even  made  of 
the  sound  for  correcting  malpositions  of  that  organ.  Abscess  of  the 
uterus  was  recognized,  and  the  description  of  the  examination  for  its 
diairnosis  and  the  methods  for  its  treatment  would,  barring;  certain 
crudities  of  expression,  pass  muster  even  in  the  light  of  our  more 
advanced  knowledge  of  uterine  ailments  and  the  means  of  their 
relief.  The  treatment,  medical  and  surgical,  laid  down  for  pelvic 
abscess  would  do  no  discredit  to  the  modern  gynecologist.  The 
relief  of  stenosis  of  the  os  by  means  of  sponge  tents  is  so  graphically 
described  as  either  to  compel  the  belief  that  the  modern  discoverer  of 
this  use  of  these  devices  derived  his  knowledge  from  the  writings  of 
iEtius,  or  to  cause  the  reader  to  mars^el  at  the  remarkable  coincidence. 
Atresia  of  the  vagina  is  discussed,  and  the  operation,  with  instruments 
therefor,  for  its  relief  clearly  described. 

The  next  writer  in  chronological  order  whose  MTitings  are  preserved 
to  us  is  Paul  of  ^^gina,  between  whom  and  JEtiiis  there  intervenes  a 
century.  This  writer  has  been  accorded  a  prominence  which  he  does 
not  merit.  Dr.  Adams,  the  translator  of  the  Sydenham  series,  has 
shown  him  much  consideration.  A  study  of  his  writings  in  connection 
with  those  of  ^Etius  reveal  him  to  have  been  a  plagiarist.  He  was  at 
most  a  compiler,  and  his  efforts  even  in  this  direction  fell  far  short  of 
those  of  the  industrious  and  able  ^Etius. 

Following  Paulus  ^Egineta  we  have  a  millennium  of  darkness,  the 
gloom  being  relieved  only  by  the  uncertain  glints  with  which  the  Sar- 
acens sought  to  make  amends  for  their  damnable  vandalism  in  the 
matter  of  the  Alexandrian  Library.  But  an  insuperable  obstacle  to 
their  progress  in  the  knowledge  of  the  diseases  of  women  ])resented 
itself  in  the  Moslem  religion,  which  forbade  visual  and  digital  exami- 
nation of  the  female  genitalia,  even  under  conditions  of  the  most  intol- 
erable suffering,  by  male  physicians.  The  ability  of  the  Saracen  physi- 
cians, so  abundantly  illustrated  in  other  departments  of  medicine,  was 


22  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

therefore  forbidden  an  opportunity  of  manifesting  itself  in  this,  and 
such  knowledge  as  formed  the  basis  of  their  unsatisfactory  practice  in 
gynecology  was  derived  solely  from  the  writings  of  the  Greeks ;  and 
the  fact  that  any  treatment  of  a  local  nature  which  might  have  been 
deemed  necessary  must  be  applied  by  ignorant  mid  wives  caused  this 
branch  of  medicine  to  soon  fall  into  desuetude  and  consequent  decay. 
Of  the  Arabian  writers,  Albucasis,  in  the  fourteenth  century,  alone 
seems  to  have  given  it  any  considerable  attention,  and  there  is  internal 
evidence  in  his  writings  that  he  was  a  Jew,  and  was  thus  not  hindered 
by  any  religious  scruples  of  his  own  from  pursuing  his  studies  after 
the  manner  proscribed  by  the  Moslem  religion.  He  makes  an  occa- 
sional allusion  to  the  speculum,  but  doubtless  the  circumstances  under 
which  he  lived  made  even  his  employment  of  it  rare.  Although  it  is 
apparent  from  the  writings  of  subsequent  authors,  and  notably  Ambrose 
Pare  (1509-90)  and  Scultetus  (1683),  that  the  instrument  was  not  abso- 
lutely forgotten,  it  is  nevertheless  a  fact  that  for  a  thousand  years  prior 
to  its  rediscovery  (if  such  it  really  was)  by  R^camier  (1816)  it  was 
practically  a  lost  instrument,  and  gynecology  certainly  was  during  this 
millennium  a  lost  art. 

While,  as  intimated  at  the  outset,  American  gynecology,  dating  from 
the .  earliest  attention  to  this  branch  of  medicine  by  the  profession  of 
this  country,  is  continuous  with  gynecology  as  we  have  traced  it  in 
outline  from  its  earliest  dawn  in  the  Old  World,  its  achievements  prior 
to  the  renaissance  ushered  in  by  Recamier  cannot  be  said  to  have  been 
of  sufficient  importance  to  entitle  it  to  a  distinctive  national  name.     It 
must  not  be  inferred  from  this  that  this  division  of  medicine  was  more 
neglected  on  this  side  the  Atlantic  than  on  the  other,  or  that  the  Amer- 
ican woman  whose  means  forbade  a  visit  to  the  European  centres  was 
obliged  to  suffer  from  her  ailments  without  having  held  out  to  her 
by  native  talent  as  much  hope  as  could  be  promised  abroad.     While  it 
may  have  been  true,  as  charged  by  Dr.  Douglass,  that  there  was  in  his 
day  (1717)  "  more  danger  from  the  physicians  of  Boston  than  from  the 
distemper,"  this  condition  of  affairs  had  much  improved  when  the  War 
of  Independence  was  declared.     The  writings  of  Joseph  Osgood  of 
Andover  and  Joseph  Orne  and  Augustus  Holyoke  of  Salem  evince  a 
knowledge  of  the  diseases  of  women  which  was  probably  quite  abreast 
of  that  possessed  by  their  European  contemporaries.    In  the  year  1790, 
nine  years  after  its  organization,  the  Medical  Society  of  Massachusetts 
first  published  such  of  the  contributions  as  were  presented  before  that 
body.      Among  these  publications  is  found  an  occasional  article  on 
some  gynecological  subject,  but  the  first  which  was  devoted  to  a  subject 
unconnected  with  the  puerperal  condition  was  one  entitled  "  The  His- 
tory of  a  Hemorrhage  from  a  Eupture  on  the  Inside  of  the  Left  I^abium 
Pudendi."     This  was  contributed  by  Dr.  Nathaniel  W.  Appleton  of 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  23 

Boston,  aiul  a|)|)('ars  in  the  second  [)art  of  the  first  volnnic  of  tin; 
Trdn-sdvdcius  of  tlir  society,   issncd   in  the  year   1<S()(J. 

The  inlhicnce  of  the  teachings  of  8niellie  and  linnter  very  naturally 
cxtcndeil  to  tlu'  prtiicssion  in  the  colonies,  and  abundant  evidence  of  it 
is  found  in  the  reports  of  eases  in  such  literature  of  the  colonial  days 
as  is  extant.  The  causes,  however,  which  operated  to  the  repression  of 
progress  in  gynecology  were  operative  here  as  in  Europe ;  and  while 
we  believe  that  the  latent  energies  of  the  profession  of  the  New  World, 
necessarily  thrown  ({uite  entirely  on  its  own  resources,  must  in  course 
of  time  have  transcended  in  their  results  the  achievements  of  the  pro- 
fession abroad,  the  struggle  inaugui-ated  by  the  Declaration  of  Inde- 
pendence diverted  those  energies  into  channels  which  were  incompat- 
ible Avith  scientific  research.  For  seven  long  years  the  struggle  for 
personal  and  national  existence  not  only  forbade  the  development 
of  the  native  resources,  but  it  also  shut  the  profession  out  from  the 
influence  of  the  mysterious  awakening  from  the  lethargy  of  centuries 
which  was  going  on  in  Europe.  Nor  did  the  cessation  of  hostilities 
leave  the  road  to  professional  progress  free  and  unobstructed.  The  vic- 
tory had  been  achieved,  but  at  a  cost  of  life  and  energy  and  treasure 
which  caused  a  depression  from  which  it  required  many  years  to  rally. 
Although  the  profession  of  medicine,  which  has  for  its  object  the  health 
of  the  people — the  supreme  law — is  a  very  essential  factor  in  national 
growth,  there  are  other  matters  which  are  more  immediately  pressing 
in  seasons  of  great  national  depression — agriculture,  manufactures,  com- 
merce. For  a  couple  of  decades  following  the  close  of  the  war  these 
were  held  to  be  of  paramount  concern,  and  it  was  not  until  the  opening 
of  the  present  century  that  the  profession  of  this  country  found  itself 
in  a  position  to  devote  even  a  portion  of  its  energies  to  the  special 
development  of  any  particular  division  of  the  whole  field  of  medicine 
which  commanded  its  attention. 

It  was  a  happy  coincidence  that  the  profession  in  America  found 
itself  sufficiently  recovered  from  the  distractions  of  war  to  permit  of 
its  placing  itself  in  the  line  of  the  movement  in  gynecology  inaugurated 
by  Hunter  in  England,  and  stimulated  to  unprecedented  activity  by  the 
revival  of  the  speculum  by  Recamier  in  France.  The  comparative 
leisure  and  wealth  which  followed  in  the  Avake  of  the  prosperity  ensured 
by  the  elasticity  of  our  people  made  it  possible  for  the  profession  to 
embrace  the  opportunity,  which,  had  it  presented  a  decade  sooner,  would 
of  necessity  have  been  allowed  to  pass  by  unimproved.  The  dawn  of 
the  present  century  found  our  young  men  and  many  of  our  older  prac- 
titioners repairing  to  the  mother-country  and  to  the  various  seats  of 
learning  in  Europe,  and  drinking  in  the  spirit  of  the  revival,  and 
bringing  it  back  wnth  them  to  these  shores.  Among  these  young  men 
was  one  Ephraim  ]\IcDowell,  who  was  born  in  Virginia  in  1771,  and 


24  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

who  moved  thence  with  his  father  and  the  rest  of  the  family  to  settle 
in  Kentucky  in  the  year  1783.  Young  McDowell  was  accorded  the 
educational  advantages  of  that  early  day  in  that  new  country.  His 
subsequent  writings  show  that  his  literary  acquirements  were  not  of  a 
much  higher  order  than  we  could  have  expected  under  the  unpropitious 
circumstances.  After  leaving  school  he  studied  medicine  for  two  or 
three  years  with  a  Dr.  Humphreys  of  Staunton,  Virginia,  a  graduate 
of  the  University  of  Edinburgh.  When  we  recall  the  contempt  which 
the  physician  educated  abroad  entertained  in  those  days  for  American 
educational  institutions,  we  are  not  surprised  at  finding  no  evidence  of 
McDowell's  having  attended  any  lectures  in  Philadelphia,  then  the  only 
seat  of  medical  education  in  this  country.  At  his  preceptor's  dictation, 
doubtless,  he  went  to  Edinburgh,  where  during  the  sessions  of  1793 
and  1794  he  attended  lectures  in  the  famous  university,  then  in  the 
zenith  of  its  renown.  Not  fully  satisfied,  however,  with  the  regular 
course  of  the  university  on  the  subject  of  surgery,  he  took  a  private 
course  under  Mr.  John  Bell,  a  surgeon  noted  alike  for  his  enthusiasm, 
his  eloquence,  his  skill,  and  his  hold  on  the  affections  of  his  students. 
We  have  no  evidence  that  McDowell  ever  graduated.  Mr.  Bell  is  said 
to  have  been  an  enthusiast  on  the  subject  of  organic  diseases  of  the 
ovaries,  and  to  have  even  discussed  the  possibility  of  their  successful 
removal,  although  never  himself  venturing  to  practically  demonstrate 
this  possibility.  Doubtless,  the  young  Kentuckian  resolved  while  under 
the  spell  of  his  teacher's  enthusiasm  to  undertake  what  that  teacher's 
timidity,  perhaps,  kept  him  from  attempting,  and  he  returned  to  his 
Western  home  inspired  with  the  high  resolve.  He  settled  in  Danville 
in  1795.  Although  but  twenty-four  years  of  age,  the  fame  of  his 
sojourn  at  foreign  seats  of  learning,  and  of  the  fact  that  he  had  studied 
under  John  Bell,  whose  reputation  had  long  before  crossed  the  seas, 
soon  secured  for  him  a  large  clientele.  Patients  soon  flocked  from  all 
parts  of  the  South-west,  and  for  hundreds  of  miles  around  he  had  the 
monopoly  of  the  important  operations.  He  had  been  in  practice  four- 
teen years  when  he  was  consulted  by  a  Mrs.  Crawford,  who  sufiered 
from  a  large  abdominal  tumor  which  a  careful  examination  convinced 
McDowell  was  ovarian.  Here  was  the  opportunity,  and  the  man  was 
equal  to  it.  The  teachings  of  Bell  had  fallen  in  fruitful  soil,  and  the 
time  of  their  fruition  had  arrived.  Mrs.  Crawford  was  no  ordinary 
woman,  and  when  McDowell  declared  to  her  that  her  only  hope  lay  in 
the  removal  of  her  tumor,  explaining  to  her  the  fact  that  such  an 
operation  had  never  before  been  undertaken,  and  admonishing  her  of 
the  dangers  which  attended  it,  the  brave  woman  placed  herself  unre- 
servedly in  the  brave  man's  hands.  The  consultation  was  held  at  Mrs. 
Crawford's  residence,  sixty  miles  from  Danville,  and  Dr.  McDowell 
made  it  a  condition  of  his  operating  that  his  patient  come  to  his  home 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  25 

for  the  oporation.  The  h(M'oine  travelled  thi.s  distanee  on  horseback, 
wa-^  operated  on  in  Deeend)er,  LSOi),  she  l)ein(j^  then  forty-seven  years 
of  age,  and  at  the  end  of  twenty-live  days  returned  to  her  home,  where 
she  lived  for  thirty -two  more  years,  during  which  she  enjoyed  for  the 
most  part  excellent  health,  and  died  at  length  in  the  seventy-ninth  year 
of  her  age.  \Mien  we  remember  the  facts  that  this  first  oi)eration  for 
the  removal  of  an  ovarian  tumor  was  performed  before  the  days  of 
anrcsthesia,  and  that  Dr.  McDowell  had  none  of  the  advantages  of  the 
trained  assistants  and  perfected  instruments  which  are  now  deemed 
so  essential  to  the  success  of  this  operation,  the  courage  of  the  woman 
and  the  skill  and  intelligent  daring  of  the  surgeon  combine  to  form  a 
picture  which  is  unique  for  its  grandeur  in  the  annals  of  surgery. 
Dr.  McDowell's  delay  in  reporting  this  case  of  ovariotomy  was 
in  singular  contrast  with  the  more  commendable  practice  of  these  later 
days.  Instead  of  immediately  giving  a  description  of  his  wonderful 
case  for  the  benefit  of  his  contemporaries,  he  waited  for  seven  years, 
during  which  time  he  successfully  performed  two  other  ovariotomies. 
His  report  of  these  three  cases  appeared  in  the  October  (1816)  issue 
of  the  Eclectic  Repertory  and  Analytical  Review.  It  was  a  docmnent 
remarkable  for  its  brevity,  that  portion  of  it  covering  the  case  which 
has  made  his  name  immortal,  and  which  demonstrated  the  practicability 
of  a  procedure  which  more  than  any  other  has  lengthened  the  average 
of  woman's  life  and  diminished  the  sum  of  her  sorrow,  not  occupying 
more  space  than  a  page  the  size  of  that  on  which  this  sketch  appears. 
The  incision  was  made  about  three  inches  from  the  musculus  rectus 
abdominis  on  the  left  side,  parallel  to  the  fibres  of  this  muscle,  and 
nine  inches  in  length  and  extending  into  the  abdomen.  The  abdominal 
parietes  were  found  to  be  very  much  contused,  owing,  it  was  supposed, 
to  the  tumor's  resting  on  the  horn  of  the  saddle  during  the  journey. 
A  ligature  was  thrown  around  the  Fallopian  tube  near  the  uterus,  Avhen 
the  tumor  was  cut  open,  and  "  fifteen  pounds  of  a  dirty,  gelatinous- 
looking  substance  "  removed.  The  sac  was  afterward  amputated  at  the 
ligature,  and  was  found  to  weigh  seven  pounds  and  a  half.  As  soon  as 
the  external  opening  was  made  the  intestines  rushed  out  on  the  table, 
and  so  completely  was  the  abdomen  filled  by  the  tumor  that  they  could 
not  be  replaced  during  the  operation,  which  was  terminated  in  about 
tw'enty-five  minutes.  The  woman  was  then  placed  on  her  left  side,  so 
as  to  permit  the  blood  to  escape,  after  which  the  external  opening  was 
closed  with  the  interrupted  suture,  leaving  out  at  the  lower  end  of  the 
incision  the  ligature  which  surrounded  the  Fallopian  tube.  Between 
every  two  stitches  was  put  a  piece  of  adhesive  plaster,  which,  by  keep- 
ing the  parts  in  contact,  hastened  the  healing  of  the  incision.  The 
usual  dressing  was  then  applied,  the  patient  put  to  bed,  and  placed  on 
a  strict  antiphlogistic  regimen.     On  visiting  her  five  days  after,  Dr. 


26  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

McDowell  was  astonished  to  find  his  patient  engaged  in  making  up 
her  bed. 

The  other  two  cases  occurred  in  negro  women,  and  the  space  devoted 
to  the  consideration  of  both  of  them  is  less  than  that  taken  up  by  a 
description  of  the  first  operation.  The  whole  report  was  loosely  and 
carelessly  constructed,  and  poorly  calculated  to  inspire  confidence  in  the 
author's  literary  and  scientific  attainments.  Had  McDowell  been  gifted 
with  facility  of  expression  the  recognition  of  his  operation  would 
doubtless  have  been  more  prompt.  At  his  death,  in  1830,  it  had  not 
yet  been  looked  upon  with  favor,  although  he  had  himself  performed 
it  thirteen  times  in  all,  with  at  least  eight  successes.  The  report  of  the 
first  three  cases  having  been  sent  to  Dr.  Physick  of  Philadelphia,  "the 
Father  of  American  Surgery,"  and  at  that  time  the  leader  of  the  Amer- 
ican profession,  it  failed  to  interest  him,  his  opinion  of  the  backwoods 
surgeon  being,  probably,  largely  influenced  by  the  display  of  his  literary 
ability.  The  report  was  also  sent  to  the  operator's  old  preceptor,  John 
Bell,  but,  owing  to  that  gentlemen's  ill-health,  he  was  at  the  time  absent 
on  the  Continent,  and  as  he  died  not  long  afterward  at  Rome,  he  never 
received  it.  The  paper  fell  into  the  hands  of  Mr.  Lizars  of  Edinburgh, 
by  whom  it  was  published  in  the  Edinburgh  3Iedical  and  SurgicalJour- 
nal  in  1824.  Mr.  Lizars,  with  the  instinct  of  a  true  surgeon,  detected 
its  merit,  and  was  the  first  to  perform  McDowell's  operation  in  Great 
Britain.  This  recognition  of  the  Kentucky  surgeon  by  his  eminent 
Edinburgh  contemporary  won  for  the  prophet  and  his  operation  an 
honor  in  his  own  country  which  he  had  previously  been  denied. 

Dr.  McDowell  when  he  operated  on  Mrs.  Crawford  had  a  reputation 
which  was  only  local,  or  he  was  at  least  known  within  but  compara- 
tively circumscribed  limits  from  his  own  home.  His  name  did  not 
appear  on  the  list  of  the  great  surgeons  of  his  day,  and — such  is  one 
of  the  peculiarities  of  human  nature — when  it  was  discovered  that  his 
claims  did  not  deserve  the  ridicule  with  which  they  Avere  greeted  even 
in  quarters  in  which  one  would  suppose  they  would  at  least  have 
received  respectful  attention,  if  not  indorsement,  envy  began  to  take 
the  place  of  ridicule.  Accordingly,  efforts  were  soon  made  to  rob  him 
of  the  honor  of  his  great  accomplishment,  and  claims  were  set  up  for 
a  number  who  were  alleged  to  have  previously  performed  the  operation. 

It  is  scarcely  necessary  in  this  place  to  review  the  nature  of  these 
claims  or  to  discuss  their  validity.  Suffice  it  to  say  that  they  were  all 
carefully  investigated  by  the  late  Dr.  Samuel  D.  Gross,  and  by  him 
pronounced  untenable. 

While  the  operation  by  McDowell  marked  an  era  in  gynecology, 
two  years  before  he  performed  it  an  American,  Dr.  John  Stearns  of 
Saratoga  county,  New  York,  had  given  to  medicine  the  drug  ergot, 
which  was  destined  to  become  one  of  the  most  important  agents  in  both 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  27 

gynceoloj^v  and  niidwif'erv.  It  is  true  the  drut»;  had  Ion;:;  Ix'f'oro  been 
empirically  enipKtyetl  by  European  niidwives,  but  Dr.  Stearns  was  tlie 
first  to  reclaim  it  from  such  unscientific  use  by  discovering  its  modus 
operandi.  The  publication  of"  his  pa})er  in  the  New  York  Mediad 
Repofi'dory  in  1807  at  once  gave  the  drug  a  place  in  the  physician's 
armamentarium,  and  its  judicious  employment  since  then  has  been  the 
means  of  relieving  perhaps  as  large  a  percentage  of  woman's  suffering 
as  any  one  surgical  procedure. 

The  next  in  chronoloo-ical  order  to  jSIcDowell  who  undertook  to 
remove  an  ovarian  tumor  in  this  country  was  Dr.  Nathan  Smith  of 
Yale,  who,  it  is  claimed,  was  not  at  the  time  aware  of  McDowell's 
achievement.  His  first  operation  was  performed  on  July  5,  1821,  and 
was  successful,  the  patient  being  able  to  walk  about  in  three  weeks. 

On  May  23,  1823,  Dr.  Alban  G.  Smith  of  Danville,  Ky.,  success- 
fully remov^ed  an  ovarian  tumor  from  a  negress  thirty  years  of  age. 
Dr.  Smith  had  made  a  previous  but  unsuccessful  ovariotomy  in  1818. 
Following  this  last  successful  case  a  number  of  unsuccessful  attempts 
were  made  by  other  surgeons,  who  in  cutting  down  to  the  tumor  found 
the  adhesions  so  extensive  as  to  deter  them  from  further  attempt  at 
removal  of  the  growth. 

The  fourth  successful  ovariotomist  of  this  country  was  Dr.  David  L. 
Rogers  of  New  York,  wdio  performed  the  operation  on  September  24, 
1829.  The  operation  lasted  two  hours,  and  at  the  end  of  two  weeks 
the  patient  was  able  to  be  up  and  about  her  room. 

In  November,  1 830,  Dr.  J.  C.  Warren  of  Boston  made  an  unsuccess- 
ful attempt  at  the  removal  of  an  ovarian  tumor.  In  December,  1835, 
Dr.  J.  Billinger  performed  a  successful  operation,  following  which  there 
are  no  records  of  any  cases  until  1843,  when  Dr.  A.  Dunlap  had  his 
first  case,  an  unsuccessful  one.  In  the  same  year  Dr.  J.  L.  Atlee  suc- 
cessfully performed  a  double  ovariotomy.  In  1844,  Dr.  Washington 
L.  Atlee,  who  did  more  than  any  other  American  surgeon  to  establish 
ovariotomy  as  a  legitimate  surgical  procedure,  had  his  first  case,  which 
terminated  unsuccessfully.  Dr.  Atlee  took  a  decided  stand  in  favor  of 
the  legitimacy  of  the  operation,  and,  although  he  encountered  a  number 
of  unsuccessful  cases,  he  faithfully  reported  them  in  detail  as  a  guide  to 
those  who  might  be  induced  to  study  the  operation  with  a  view  to 
removing  from  it  the  discoverable  reasons  for  its  mortality.  He 
encountered  violent  opposition  and  much  vituperation,  but  had  the 
satisfaction  of  living  to  witness  such  a  general  recognition  of  ovariot- 
omy as  a  legitimate  surgical  procedure  that  scarcely  any  surgeon  felt 
deterred  from  performing  it.  In  1855  he  published  a  synopsis  of 
his  first  thirty  cases,  of  which  seventeen  recovered  and  thirteen  died. 
Such  a  percentage  of  recoveries  from  a  disease  in  itself  necessarily  fatal 
silenced  opposition  to  the  operation,  and  from  that  time  the  number 


28  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

of  ovariotomists  in  this  country  has  rapidly  increased,  even  up  to  the 
present  time,  while  the  percentage  of  mortality  attending  the  operation 
by  competent  operators  has,  under  improved  methods,  antiseptic  and 
mechanical,  grown  to  be  quite  as  small  as  that  attending  most  other 
capital  operations. 

In  1853,  Dr.  Washington  L.  Atlee  read  before  the  American  Medi- 
cal Association  a  paper  on  fibrous  tumors  of  the  uterus  which  at  once 
became  a  portion  of  the  classic  gynecological  literature  of  this  country. 
It  dealt  with  such  of  these  tumors  as  had  heretofore  been  supposed  to  be 
inaccessible  to  the  knife  or  not  amenable  to  curative  measures.  The  paper 
was  based  wholly  on  the  author's  own  exjDcrience,  and  gave  important 
information  touching  the  classification  and  means  of  diagnosing  these 
tumors,  besides  indicating  a  method  of  their  treatment  by  enucleation. 
It  divided  them  into — 1,  extra-uterine  or  surface  tumors ;  2,  intra-ute- 
rine  or  cavity  tumors ;  and  3,  intramural  tumors  of  the  uterus.  The 
value  of  ergot  given  internally  as  a  remedy  was  strongly  insisted  on, 
and  the  use  of  that  drug  in  the  removal  of  these  growths  through 
absorption  due  to  pressure  from  contraction  of  the  non-striated  muscu- 
lar tissue  has  since  been  regarded  as  the  most  efficacious  means  of  treat- 
ing such  growths  as  are  inaccessible  to  the  knife. 

In  1856  there  appeared  the  prize  essay  by  Dr.  George  H.  Lyman  of 
Boston  upon  the  History  and  Statistics  of  Ovariotomy,  and  the  Oircum- 
stances  under  which  this  Oj)eration  may  be  regarded  Safe  and  Expedient. 
Up  to  that  date  Dr.  Lyman's  monograph  was,  probably,  the  most  com- 
plete of  any  that  had  appeared,  being  a  complete  and  careful  research 
of  the  ovariotomy  statistics  of  all  countries. 

In  the  same  year  Dr.  I.  E.  Taylor  advocated  a  new  operation  for  the 
cure  of  recto-vaginal  fistula,  reporting  two  cases  in  which  he  had  suc- 
cessfully employed  it.  This  operation  consisted  in  the  severing  of  the 
sphincter  ani  in  such  cases. 

Some  remarkable  operations  for  the  removal  of  the  extra-uterine 
foetus  were  performed  in  the  early  history  of  this  country.  In  1791, 
Dr.  William  Boynham  of  Virginia  successfully  removed  the  tumor  by 
incision  of  the  abdominal  parietes.  In  1799  he  performed  a  similar 
operation,  and  ^ath  equally  satisfactory  results.  In  1816,  Dr.  John 
King  of  South  Carolina  cut  through  the  walls  of  the  vagina  and 
removed  through  the  incision,  by  means  of  the  forceps  and  abdom- 
inal pressure,  a  living  child  which  had  been  carried  through  the  full 
term  of  gestation  in  the  abdominal  cavity  outside  the  uterus.  The  life 
of  the  mother  was  also  saved.  This  case  stands  on  record  as  one  of  the 
most  remarkable  ever  encountered,  and,  being  without  precedent,  does 
all  the  greater  credit  to  the  operator's  judgment  and  resolution.  In 
1874,  Dr.  T.  Gaillard  Thomas  incised  the  vaginal  wall  with  the  gal- 
vano-caustic  knife  and  removed  a  three  months'  foetus;  and  in  1875, 


HISTOnrCAL  SKErCII  OF  AMERICAN  GYSECOLOGY.  29 

Dr.  D.  Hayes  A;^ik'\v  of  Philadelphia  reported  a  case  of  vaginal  section 
perK>riiieJ  bv  himself  for  the  removal  of  au  extra-uterine  fa'tiis. 

Simon's  method  of  iutroducinj;  the  hand  into  the  rectum  for  diag- 
nostic and  therapeutic  purposes  is  not  as  new  as  many  are  disposed  to 
believe.  In  18U(j,  Dr.  Clark,  an  American,  recorded  the  fact  that  he 
introduced  his  hand  into  the  bowel,  and,  putting  his  finger  into  the 
mouth  of  an  extra-uterine  foetus,  made  traction  and  delivered  the  head 
per  rectum.  The  body  and  secundines  were  removed  spontaneously 
some  time  after.  On  the  next  day  the  anus  had  contracted  to  its  nat- 
ural size,  but  on  the  third  day  it,  as  well  as  the  perineum,  began  to 
slough.  On  the  ninth  day  the  parts  had  commenced  to  heal,  but  the 
fourchette  was  destroyed. 

Although  such  records  as  are  available  show  that  American  surgeons 
and  general  practitioners  were  quite  as  successful  in  their  treatment  of 
special  diseases  of  the  womb  as  were  their  contemporaries  abroad,  nearly 
half  a  century  had  gone  bv  since  McDowell's  discovery  before  anything 
occurred  on  this  side  of  the  Atlantic  of  a  nature  calculated  to  direct 
special  attention  to  American  gynecology.  But  the  native  shrewdness 
of  the  American  practitioner  qualified  him  for  such  utilization  of  exist- 
ing knowledge  as  made  him  the  peer  of  his  Transatlantic  brother  in 
this  special  direction.  Xot  until  the  year  1852,  however — if  we  except 
Meigs's  discovery  of  cardiac  thrombosis  as  a  cause  of  sudden  death  in 
childbed,  and  Hodge's  improvements  in  the  construction  of  uterine 
pessaries — did  any  of  the  great  Kentuckian's  countiymen  do  aught 
worthy  of  giving  them  marked  distinction  in  the  direction  of  gynecol- 
ogy. Hodge's  pessary  was  a  yer\'  decided  improvement  on  instruments 
heretofore  constructed  for  a  similar  purpose,  being  based  on  more  cor- 
rect physiological  principles  than  any  of  its  predecessors.  The  descrip- 
tion of  the  steps  which  more  immediately  preceded  the  discovery  of 
this  pessary  is  best  given  in  Dr.  Hodge's  own  words,  as  quoted  in  a 
commemorative  address  by  Dr.  Penrose  of  Philadelphia :  "  He  had 
been  contemplating  for  a  long  time  the  subject  of  new  shapes  for  pes- 
saries,-and  after  many  experiments  had  found  nothing  satisfactory.  One 
evening  Avhile  sitting  alone  in  the  room  Avhere  the  meetings  of  the  med- 
ical faculty  of  the  university  were  held  his  eyes  rested  on  an  upright 
steel  support  by  the  fireplace  designed  to  hold  the  shovel  and  tongs. 
The  shovel  and  tongs  were  kept  in  position  by  a  steel  hook,  and  as  he 
surveyed  the  supporting  curve  of  this  hook  the  longed-for  lumination 
came :  the  shape,  apparently  so  paradoxical,  revealed  itself  in  the  clear 
light  and  flickering  volume  of  the  burning  grate,  and  the  Hodge  lever 
pessar\"  was  the  result."  This  was  in  the  year  1830.  To  him  the  ])ro- 
fession  is  indebted  for  the  origin  and  development  of  two  ideas  which 
are  at  this  day  considered  among  the  most  important  facts  in  uterine 
pathology — namely,  that  the  condition  of  the  uterus  characterized  by 


30  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

enlargement,  displacement,  congestion,  hypersecretion,  and  tenderness  is 
not  inflammation,  nor  should  it  be  treated  as  such — that  sustaining  the 
uterus,  and  thus  affording  an  easy  and  natural  means  of  overcoming 
congestion  and  its  results,  is  a  prime  factor  in  their  relief  and  cure. 

In  1833,  Dr.  Walter  Channing,  professor  of  obstetrics  at  Harvard 
University,  wrote  an  article  on  "  Irritable  Uterus."  This  was  the  first 
comprehensive  monograph  upon  a  purely  gynecological  subject  in  New 
England,  besides  being  one  of  the  most  valuable  contributions  extant 
to  this  division  of  medicine. 

In  1841,  Dr.  Gunning  S.  Bedford,  one  of  the  most  graceful  writers 
of  any  age,  established  the  first  clinic  for  diseases  of  women  ever  held 
on  this  side  the  Atlantic,  in  connection  with  his  chair  of  obstetrics  in 
the  University  Medical  College  of  New  York.  In  this  year  also  Dr. 
Alonzo  Clark  of  New  York  introduced  his  plan  of  treating  peritonitis 
with  large  doses  of  opium.  This  plan  involves  the  exhibition  of  the 
drug  to  the  limit  of  profound  narcotism.  The  amount  of  it  which  is 
tolerated  by  the  patient  is  greatly  in  excess  of  that  which  he  will  bear 
in  the  physiological  condition.  It  requires  the  close  attention  of  the 
physician  in  order  that  the  limit  be  not  inadvertently  exceeded. 

In  1844,  Dr.  J.  C.  Nott  of  Mobile,  Alabama,  published  a  report  of 
a  case  of  the  removal  of  a  carious  coccyx,  which  was  followed  by  relief 
of  a  very  aggravated  coccygodynia. 

During  the  year  1852  there  appeared  in  the  American  Journal  of 
Medical  iSciences  an  article  by  an  Alabama  doctor  which  once  more 
directed  the  eyes  of  the  medical  world  to  this  country.  If  E.6camier's 
resurrection  of  the  speculum  marked  the  rise  of  modern  gynecology, 
this  article  caused  it  to  take  a  stride  unprecedented.  Recamier's  spec- 
ulum had  exposed  the  uterus,  but  it  did  so  quite  imperfectly,  and  was 
of  little  or  no  service  in  placing  the  vagina  under  surgical  control.  The 
writer  of  the  paper  referred  to  had  solved  the  problem,  and  the  surgical 
diseases  of  the  approach  to  the  w^omb  became  amenable  to  treatment, 
while  affections  of  the  womb  itself  ceased  very  largely  to  be  the  oppro- 
bria  of  the  healing  art.  If  McDowell'fj  discovery  "  has  added  forty 
thousand  years  to  the  sum  of  human  life,"  who  can  compute  the  sum 
of  happiness  to  the  mind  and  misery  averted  through  this  discovery  by 
J.  Marion  Sims?  The  paper  by  him  on  vesico-vaginal  fistula  made 
his  title  of  "  Father  of  American  Gynecology  "  indisputable,  and  the 
discovery  which  it  recorded  has  made  surgery  of  the  uterus  and  vagina 
a  wellnigh  exact  science.  The  discovery  of  the  operation  for  the  cure 
of  a  disease  previously  incurable  was  in  itself  a  great  achievement,  but 
the  discovery  of  a  method  of  so  distending  the  vagina  by  air  as  to 
render  this  operation  and  all  other  necessary  operations  on  the  vagina 
and  womb  possible  was  a  greater  achievement.  Gynecology  to-day 
would  scarcely  deserve  the  name  of  a  separate  branch  of  medicine  but 


HISTORICAL  SKETCH  OF  AMIJRICAN  CYNECOLOGY.  81 

for  Siiiis's  dist'overv.  It  has  hccii  ;i|)|>i-(i|)ri:i(cly  said  that  "  it  Ikls  hccn 
to  diseases  ot"  tlic  woiul)  wliat  the  priiitinii-prcss  is  to  civilization,  what 
the  coinpjLss  is  to  the  niariiu'i-,  what  steam  is  to  navigation,  wiiat  the 
teleseope  is  to  astronomy  ;  and  ^rancU'i-  than  the  telescope,  because  it 
was  the  work  ot"  one  man." 

Wliile  the  grand  results  to  gynecology  which  the  genius  of  Sims  has 
evolved  are  the  outeonie  of  that  careful  study  and  constant  effort  which 
are  the  essentials  to  most  of  such  results  in  science  as  are  destined  to 
live,  the  discovery  of  the  fact  which  brought  his  mind  in  the  line  of 
work  which  made  him  famous  was  (piite  purely  accidental.  Singular 
as  it  may  appear,  his  tastes  were  originally  not  for  gynecological  work : 
he  was,  indeed,  quite  averse  to  treating  diseases  of  the  female  sexual 
apparatus,  and  even  to  the  necessary  means  of  examination  for  making 
a  diagnosis  of  such  affections.  He  had,  after  perhaps  more  than  the 
usual  share  of  vicissitudes  and  discouragements  which  beset  the  young 
practitioner,  and  extending  through  an  unusual  length  of  time,  suc- 
ceeded in  gaining  the  confidence  of  the  community  in  which  he  lived 
and  in  establishing  a  reputation  as  a  general  surgeon.  He  was  one  day 
called  in  consultation  in  a  case  of  labor  in  which  the  head  had  been 
impacted  for  nearly  three  days.  He  delivered  the  woman  quite  readily 
with  the  forceps,  and  she  rallied  well  from  the  operation.  Five  days 
later  she  was,  however,  discovered  to  have  an  extensive  slough  of  the 
soft  parts,  and  was  discharging  both  urine  and  feces  through  the  vagina. 
He  had  then  been  in  practice  ten  years,  and  this  was  the  first  case  of 
vesico- vaginal  fistula  which  he  had  encountered.  After  consulting  the 
literature  on  the  subject,  he  was  convinced  of  the  very  rebellious  nature 
of  the  accident  to  treatment,  and  in  spite  of  the  importunities  of  the 
owner  of  the  woman  (who  was  a  slave),  he  refused  to  undertake  an 
operation  for  its  relief.  In  one  month  from  that  time  he  was  consulted 
in  reference  to  a  vesico-vaginal  fistula  existing  in  the  case  of  another 
negro  slave,  and  again,  in  about  another  month,  a  third  case  came 
under  his  notice.  This  unusual  number  of  cases  presenting  within 
such  a  short  time  compelled  his  attention  to  the  disease,  and,  as  he  had 
established  a  small  hospital,  the  three  cases  were  placed  under  his  care 
in  the  hope  that  he  might  devise  some  means  of  relief.  While  per- 
plexed with  these  cases  he  was  one  morning  suddenly  called  to  see  a 
lady  who  had  been  thrown  from  her  horse.  After  due  examination  he 
concluded  that  the  distressing  pain  from  which  the  ^^'oman  suffered  was 
caused  by  a  dislocation  of  the  uterus.  Recalling  a  ride  for  the  treat- 
ment of  this  accident  which  had  been  given  him  while  a  student,  he 
placed  the  patient  on  her  knees  and  elbows,  and,  introducing  one  finger 
into  the  rectum  and  another  into  the  vagina,  "  pushed  up  and  pulled 
down"  according  to  directions.  Finding  that  he  could  just  reach  the 
uterus  with  his  index  finger,  which  was  not  long  enough  to  permit  him 


32  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

to  exert  any  force  on  the  organ,  he  introduced  also  the  middle  finger ;  and 
in  his  effort  to  push  the  uterus  back  turned  his  hand  palm  upward  and 
then  downward,  when  all  at  once  he  could  feel  neither  the  womb  nor 
the  walls  of  the  vagina.  Immediately  the  woman  declared  she  was 
relieved.  As  she  turned  on  her  side  there  was  a  sudden  explosion,  as 
though  of  air  escaping  from  the  bowel.  He  was  satisfied,  however, 
that  the  air  was  not  from  this  source,  but  was  from  the  vagina,  and 
concluded  that  his  traction  on  the  perineum  had  suddenly  created  a 
vacuum  into  w^hich  the  air  rushed  and  expanded  the  vagina  to  its  fullest 
capacity.  Fired  with  a  new  idea  which  had  just  been  forced  upon 
him,  he  hurried  home  in  order  to  test  it  in  the  case  of  the  unfortunates 
suffering  from  vesico-vaginal  fistula  in  his  hospital.  On  his  way  he 
had  stopped  and  bought  a  large  pewter  spoon,  which  he  bent  so  as  to 
secure  the  necessary  purchase  for  retracting  the  perineum,  as  he  had 
discovered  he  had  accidentally  done  in  the  case  of  the  woman  suffering 
from  the  dislocation  of  the  womb.  Selecting  one  of  his  patients,  he 
placed  her  on  a  table  in  the  genu-pectoral  position,  and,  placing  a 
student  on  eacli  side,  instructed  them  to  lay  hold  of  the  nates  and  pull 
them  open.  Before  he  could  get  the  bent  spoon-handle  into  the  vagina 
the  air  rushed  in  with  a  puffing  noise,  dilating  the  cavity  to  its  fullest 
extent.  On  making  further  traction  with  the  spoon  he  had  revealed 
to  him  a  sight  which  had  never  before  been  seen  by  any  man.  The 
fistula  with  its  edges  clearly  defined  was  plainly  visible ;  the  wall  of 
the  vagina  could  be  seen  closing  in  every  direction ;  the  neck  of  the 
uterus  was  distinct  and  well  defined,  and  even  the  secretions  therefrom 
could  be  plainly  seen. 

He  at  once  devised  and  had  made  for  him  the  instruments  which  he 
considered  to  be  necessary  for  closing  up  the  fistula.  Among  these 
instruments  was  the  duck-bill  speculum,  to  which  his  name  has  been 
inseparably  attached ;  and  it  is  a  singular  fact  that  the  original  design 
of  that  instrument  has  never  been  altered.  It  took  him  three  months 
to  have  the  necessary  instruments  made,  and  the  case  which  he  selected 
for  the  operation  was  an  unusually  bad  one,  the  whole  base  of  the 
bladder  being  destroyed,  leaving  an  opening  between  the  vagina  and 
that  viscus  at  least  two  inches  in  diameter.  This  was  in  December, 
1845,  and  before  the  discovery  of  ansesthesia.  He  succeeded  in  clos- 
ing the  fistula  in  about  an  hour's  time.  In  order  to  prevent  the  urine 
from  dripping  through  into  the  vagina,  he  placed  a  piece  of  sponge  in 
the  neck  of  the  bladder,  through  which  he  ran  a  silk  string  which 
he  hoped  would  act  as  a  capillary  tube  that  would  serve  to  turn  the 
course  of  the  urine  from  the  fistula.  This  latter  device  proved  to  be 
a  very  unfortunate  one.  At  the  end  of  five  days  the  patient  was  very 
ill  from  what,  in  more  recent  times,  has  come  to  be  known  as  blood- 
poisoning.     On  attempting  to  remove  the  sponge,  he  found  that  it  had 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  33 

beeomo  soliditictl  with  sabulous  matter  Iruui  the  urine,  and  he  had 
great  difficulty  in  reniovin<j;  it.  On  examining  the  fistula,  he  found 
that  it  had  disap})eared  with  the  exception  of  two  small  openings  in 
the  line  of  the  union  of  its  edges.  Eneoiu-aged  by  this  })ron()uneed 
success  in  healing  the  opening,  he  was  confident  that  the  small  remain- 
ing apertures  could  be  closed  by  a  subsequent  operation ;  before  per- 
forming which,  however,  he  operated  on  another  of  his  patients,  using 
in  this  case  a  self-retaining  catheter  instead  of  the  sponge.  At  the  end 
of  seven  days  he  removed  the  sutures,  but  discovered  that  though  the 
original  fistula  had  been  greatly  changed  in  character,  there  still 
remained  three  little  openings  through  which  the  urine  escaped.  In 
spite  of  the  repeated  operations,  having  operated  some  thirty  times  on 
one  of  the  cases,  extending  through  a  period  of  three  years,  he  found 
himself  unable  to  effect  a  complete  closure  of  the  fistula  in  any  case. 
He  finally  concluded  that  he  should  not  perform  another  operation 
until  he  had  discovered  some  method  of  trying  the  suture  higher  up 
in  the  body  than  he  could  reach.  While  lying  in  bed  one  night  the 
idea  occurred  to  him  to  run  a  perforated  shot  along  the  suture  to  the 
edge  of  the  fistula,  and  when  it  was  drawn  tight  to  compress  it  Avith  a 
pair  of  forceps,  thus  making  the  knot  perfectly  secure.  Elated  with 
this  idea,  he  conducted  flirther  operations,  but  with  scarcely  any  better 
success  than  heretofore.  He  was  now  convinced  that  the  cause  of  the 
failure  lay  in  the  nature  of  the  material  employed  for  sutures — namely, 
silk  thread — and  his  nest  object  was  to  secure  some  substitute.  Mat- 
tauer  of  A^irginia  had  employed  lead,  and  Sims  had  tried  this  material 
as  a  suture  in  his  cases  of  vesico-vaginal  fistula,  and  had  failed.  At 
this  juncture,  in  walking  from  his  house  to  his  office  one  day,  he  picked 
up  a  little  piece  of  wire.  Taking  this  to  a  jeweller,  it  served  as  a  pat^ 
tern  for  some  pure  silver  wire  which  he  ordered.  In  the  next  opera- 
tion the  edges  of  the  womb  were  denuded  and  brought  together  with 
four  sutures  of  wire  thus  prepared,  the  suture  being  closed  by  means 
of  the  shot  run  upon  the  wire  and  pressed  with  the  forceps  when  run 
sufficiently  far  up.  In  using  silk  sutures  cystitis  always  resulted  in 
the  case  of  operations  at  the  base  of  the  bladder,  the  urethra  lieing 
always  swollen  and  the  urine  loaded  with  thick,  ropy  mucus.  AVith 
the  use  of  the  silver  suture  there  was  a  complete  change  in  these  con- 
ditions. After  a  week  had  passed  the  patient  M'as  removed  from  the 
bed  and  placed  upon  an  operating-table,  and  with  an  anxious  heart 
the  result  of  the  use  of  the  wire  suture  was  examined.  There  lay  the 
suture  apparatus  just  exactly  as  it  had  been  placed,  with  no  inflam- 
mation, no  tumefaction,  and  perfect  union  of  the  fistula.  At  last  the 
labors  of  three  years  had  been  crowned  with  success,  and  vesico-vagi- 
nal fistula  was  removed  from  the  list  of  incurable  affections.  In  the 
course  of  two  weeks  the  remaining  patients  in  the  hospital  were 
Vol.  I.— 3 


34  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

operated  on,  and  in   every   case  the   results   were   completely  satis- 
factory. 

While  it  is  manifestly  the  duty  of  the  historian  to  select  for  his  nar- 
rative, without  bias  or  favor,  facts  which  he  regards  as  the  most  indis- 
putable, he  ought  not  to  be  accused  of  exceeding  his  duty  when  he 
notices  claims  which,  although  not  disposed  to  concede  them,  he  may 
regard  as  entitled  to  respectful  consideration.  The  name  of  Sims  will 
live  in  the  history  of  medicine  as  that  of  the  father  of  American 
gynecology,  but  it  is  only  just  to  state  that  the  claims  of  priority  for 
some  at  least  of  the  achievements  which  have  won  him  this  proud 
title  have  been  disputed.  Among  those  who  have  contested  these 
claims,  his  contemporary.  Dr.  Nathan  Bozeman,  has  been  prominent. 
He  was  associated  with  Sims  in  the  early  years  of  their  practice,  and 
became  his  successor  at  Montgomer}^,  Alabama,  on  Sims's  removal  to 
New  York.  Unfortunately,  a  dispute  as  to  the  authorship  of  several 
of  the  devices,  wdiich  have  made  the  operation  for  vesico-vaginal  fistula 
a  success,  developed  in  later  years,  and  became  tainted  with  a  consider- 
able degree  of  acrimony.  "With  this  dispute  we  have  nothing  to  do, 
further  than  to  state  that  while  history  will  endorse  Sims's  right  to  all 
that  he  claims  in  connection  with  the  discovery  and  perfection  of  the 
operation,  it  will  not  deny  to  Bozeman  an  important  part  in  helping 
to  establish  the  foundation  on  which  American  gynecology  is  erected. 
Dr.  Bozeman  subsequently  followed  Dr.  Sims  to  New  York.  Among  the 
discoveries  with  which  his  name  will  continue  to  be  associated  are  his 
knee-chest  support,  his  self-retaining  speculum,  his  button  sutures — 
instruments  and  methods  now  but  little  used ;  also  his  method  of  auto- 
plasty  by  gradual  approaches,  and  his  operation  for  the  cure  of  chronic 
cystitis  through  the  establishment  of  a  fistula  leading  into  the  vagina. 
This  operation  was  also  independently  discovered  in  the  same  year  by 
Dr.  T.  A.  Emmet,  who  was  the  first  to  give  it  to  the  profession  in  1868, 
Dr.  Bozeman's  paper  not  having  been  published  until  1871. 

Dr.  Sims's  achievements,  on  which  what  may  be  called  American 
gynecology  is  founded,  were  wrought  out  in  an  obscure  Southern  town 
and  while  engaged  in  the  commonplace  duties  of  the  country  general 
practitioner.  With  no  prestige  of  college  connection,  and  none  of  the 
backing  which  is  generally  considered  necessary  to  distinction  in  a  spe- 
cialty, he  won  for  himself  the  proud  distinction,  "  Father  of  American 
Gynecology."  It  was  necessary,  however,  after  having  thus  laid  this 
essential  foundation  that  it  should  become  known  to  the  profession. 
To  this  end  Dr.  Sims  determined  to  repair  to  one  of  the  medical 
centres,  and  this  the  precarious  state  of  his  health  compelled  him  to 
do  sooner  than  he  would  have  otherwise  done.  Being  the  victim 
of  a  chronic  diarrhoea,  his  complaint  made  it  necessary  for  him  in 
1853  to  remove  from  the  scenes  of  his  distinguished  labors,  and  he 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOCY.  35 

deeicled  on  New  York  as  his  future  home.  The  story  of  his  earlier 
years  in  that  eity  furnishes  us  a  sin<i;ular  ilhistration  of  the  jealousy 
of  the  obseure  praetitioncr  on  the  j)art  of  the  gentlemen  eonneeted  with 
the  medical  schools.  An  apparently  systematic  effort  was  made  to 
ap])vnpriate  his  work  without  credit,  and  the  attempts  of  certain  indi- 
viduals in  this  direction  reflect  little  credit  on  their  memory.  Alter 
encounterinj»;  o])j)osition  and  sutJering  discouragements  to  which  even 
he,  with  all  his  enthusiasm  and  force  of  character,  would  have  suc- 
cumbed but  for  the  support  and  cheer  of  an  hen^ie  wife,  he  was  thrown 
in  the  w'ay  of  a  Mr.  Henri  L.  Stuart,  who,  being  a  man  of  great  influ- 
ence in  both  the  financial  and  social  world,  and  becoming  warmly  inter- 
ested in  the  object  of  Dr.  Sims's  ambition — namely,  the  establishment 
of  a  woman's  hospital — entered  heartily  into  the  project.  At  Mr. 
Stuart's  suggestion.  Dr.  Sims  sent  out  notices  to  the  general  profession 
that  he  would,  on  a  certain  day  in  ^lay,  1854,  deliver  a  lecture  in  which 
he  would  call  the  attention  of  all  who  might  attend  to  the  work  which 
he  had  done.  In  view  of  the  treatment  which  he  had  received  at  the 
hands  of  the  gentlemen  on  whom  he  had  called  personally,  he  was  \evy 
much  encouraged  at  the  size  of  the  audience  which  had  responded  to  his 
invitation.  In  spite  of  his  innate  diffidence,  he  succeeded  in  not  only 
interesting  the  meetino;,  but  in  arousing  it  to  a  verv  considerable  decree 
of  enthusiasm.  The  plan  of  establishing  a  woman's  hospital  was 
broached,  and,  largely  through  the  influence  of  Mr.  Stuart,  the  proj- 
ect found  favor  Avith  the  public,  and  many  prominent  ladies  of  the 
city  became  actively  interested  in  the  work.  These  ladies  formed 
themselves  into  an  association,  and  in  1855  the  object  of  Dr.  Sims's 
ambition  was  realized — the  woman's  hospital  had  become  a  fact.  It 
received  very  little  encouragement  from  the  leaders  ;  that  is,  the  hospi- 
tal-men. Dr.  Sims  w^as  called  by  them  a  quack  and  a  humbug,  and 
the  hospital  was  pronounced  a  fraud.  But  in  spite  of  the  formidable 
opposition  from  this  source  the  work  went  on,  the  wards  of  the  insti- 
tution were  opened  to  any  doctor  wdio  cared  to  come,  the  operations 
were  performed  in  the  presence  of  leading  medical  men,  and  the  pro- 
fession generally  was  welcomed  to  the  institution.  The  hospital  was 
inaugurated  on  the  1st  of  May,  1855,  at  83  ^ladison  Avenue,  shortly 
after  which  Dr.  Sims  associated  with  himself  Dr.  Thomas  Addis 
Emmet,  who  Avas  at  that  time  a  young  man  and  unknown,  but  who 
has  since  won  for  himself  a  reputation  in  gynecology  second  only  to 
that  of  Sims  himself.  The  woman's  hospital  in  1857  secured  a  charter 
from  the  State,  and  has  from  that  time  been  known  as  "  The  Woman's 
Hospital  of  the  State  of  Xew  York."  This  institution  has  been  the 
most  important  factor  in  the  progress  of  American  gynecology.  Here 
it  was  that  a  systematic  method  of  treating  the  diseases  peculiar  to 
women  was  first  adopted.     Until  Sims's  connection  with  it  gynecology 


36  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

as  a  specialty  was  unknown,  he  being  the  first  to  give  attention  to  it,  to 
the  exclusion  of  all  aifections  not  coming  distinctively  under  its  head. 
Under  his  direction  the  facilities  afforded  by  the  Woman's  Hospital 
were  utilized  to  the  perfection  of  operations  on  the  perineum,  vagina, 
and  uterus,  which  previous  to  his  immortal  discoveries  had  been 
unknown,  but  which,  chiefly  through  the  knowledge  disseminated 
from  that  centre,  are  now  daily  performed  by  even  general  practitioners 
in  all  parts  of  the  world,  to  the  relief  of  untold  suffering. 

In  1861,  Dr.  Sims  visited  Europe.  His  reputation  had  preceded 
him,  and  his  reception  both  by  the  profession  and  the  pul^lic  was  in 
keeping,  and  he  soon  found  himself  with  such  a  large  clientele,  in 
nearly  all  of  the  European  medical  centres  that  he  afterward  devoted 
his  time  about  equally  between  both  sides  of  the  Atlantic,  In  1865  he 
published  his  Clinical  Notes  on  Uterine  Surgery,  in  which  he  embodied 
the  results  of  his  special  work,  describing  the  operations  which  he  had 
devised  and  the  improvements  which  he  had  made  on  the  procedures 
hitherto  in  vogue.  This  work  made  a  very  profound  impression  on 
the  professional  mind,  and  it  was  soon  translated  into  almost  all  mod- 
ern tongues.  It  was,  indeed,  the  most  distinctive  work  on  gynecology 
which  had  been  published,  and  may  be  said  to  be  the  basis  of  the  spe- 
cialty of  gynecology  as  it  exists  to-day.  Written  in  a  style  calculated 
to  carry  conviction,  it  at  once  became  the  guide  and  gave  impetus  to 
gynecological  study. 

On  Dr.  Sims's  retiracy  from  the  Woman's  Hospital  in  1862,  Dr.  T. 
Addis  Emmet  became  surgeon-in-chief,  and  under  his  charge  the  insti- 
tution continued  to  grow  both  in  popularity  and  usefulness.  FoUoAving 
the  impetus  given  by  Sims  to  gynecology  as  a  specialty,  a  number  of 
American  surgeons  gave  their  attention  exclusively  to  this  branch  of 
work,  and  among  those  who  at  an  early  date  thus  devoted  themselves 
Thomas  Addis  Emmet,  H.  R.  Storer,  Xathan  Bozeman,  E.  E,  Peaslee, 
T,  Gaillard  Thomas,  James  P,  ^^Hiite,  W,  H.  Byford,  William  Goodell, 
and  Robert  Battey  have  attained  marked  distinction,  and  American 
gynecology  bears  the  indelible  marks  of  their  labors.  Some  of  these 
gentlemen  are  dead,  and  to  write  of  them  in  terms  of  the  enthusiasm 
which  their  valuable  work  naturally  arouses  in  a  contemporary  who 
has  closely  watched  their  progress  might  be  in  keeping.  It  is,  how- 
ever, a  delicate  and  very  difficult  task  to  write  of  the  living,  and  it  must 
remain  for  a  future  historian  to  express  out  of  the  fulness  of  his  heart 
his  estimate  of  those  who,  having  done  their  life-work  in  this  direction, 
are  now  in  the  sere  and  yellow  leaf,  A  bare  record  of  their  work  is  all 
that  is  now  permissible, 

Dr,  Emmet  in  1859  withdrew  from  general  practice,  and  has  since 
devoted  himself  exclusively  to  gynecology.  He  has  been  a  diligent 
worker  in  the  field,  and  has  contributed  freely  to  medical  periodicals 


HISTORICAL  SKETCH  OF  AMh'RICAN  GYNECOLOGY.  37 

reports  of  the  nsiilts  lie  1i:h  ;iclii<'\('(l.  'I'lic  iiKtst  notable  of  his  coii- 
tril)iititms  |)('rt:iiii  to  the  siibjcct  of"  laceration  ot"  the  eei'vix  uteri,  detail- 
iiit;'  the  etiology  of  the  alfeetioii,  its  syiiij)t(»iiis,  its  oifeets  on  the  consti- 
tution, and  the  opei-ation  for  its  I'elief.  This  operation  is  now  distinct- 
ively known  as  "  Emmet's  ojK'ration."  It  was  first  (h'seribed  in  1809 
in  a  paper  road  before  the  JNIedieal  Society  of  the  County  of  New 
York,  and  pul)b"shcd  in  the  February  mnnber  (l<S()t))  of  tlie  American 
Joiii-na/  of  ()/>sl('trlcs.  In  1874  lie  j)resented  before  the  same  society  an 
article  on  lacerations  of  the  cervix  uteri  as  a  frecjneiit  and  unreco<j:;nized 
cause  of  disease.  The  writer,  not  wishing  to  anticipate  the  events  of 
later  years,  nuist  dismiss  this  subject  here,  but  will  allude  to  it  at  some 
leuiith  when  writing  of  the  occurrences  of  the  last-mentioned  year. 

In  1854,  Dr.  E.  R.  Peaslee  made  a  valuable  contribution  to  the 
treatment  of  se])tica?mia  following  ovariotcmiy.  His  method  consisted 
in  the  introduction  of  a  tube  into  the  peritoneal  cavity,  through  ^yllich 
the  serous  sac  ^^•as  freely  washed  out.  Experience  with  this  new  method 
has  done  much  to  remove  the  fear  which  was  before  entertained  of  inter- 
ference with  the  peritoneal  membrane.  After  the  lapse  of  a  third  of  a 
century  this  method  still  remains  as  the  most  reliable  for  the  treatment 
of  one  of  the  gravest  consequences  to  the  operation  for  the  removal  of 
ovarian  tumors.  In  one  of  Peaslee's  cases,  reported  at  the  time  of  his 
introduction  of  this  new  method,  intraperitoneal  injections  were  kept 
up  for  fifty-nine  days,  and  in  another  for  seventy-eight  days,  recovery 
following  in  each  case. 

In  1856,  Sims  added  another  to  his  long  list  of  brilliant  achieve- 
ments by  publishing  his  operation  for  narrowing  the  vagina  as  a  means 
of  curing  prolapsus  of  the  uterus.  This  advice  was  not  strictly  original 
with  him,  although  we  have  no  evidence  to  show  that  he  had  imitated 
any  of  his  predecessors.  The  operation  had  been  performed  in  Europe 
many  years  previously,  but  had  fallen  into  desuetude. 

Dr.  James  P.  White  of  Buffalo  during  the  same  year  reported  the 
successful  reduction  by  taxis  of  an  inverted  uterus  of  eight  davs'  stand- 
ing: Dr.  White  was  a  pioneer  in  taking  the  position  that  chronic  inver- 
sion of  the  uterus  is,  as  a  rule,  always  reducible.  He  is  distinguished  as 
the  first  successful  operator  in  the  country  to  reduce  a  chronic  inverted 
uterus.  E.  Noeggerath  in  1862  practised  reduction  of  inverted  uterus 
by  digital  compression  of  both  horns ;  and  in  1868,  Dr.  T.  Addis  Emmet 
reported  that  he  had  retained  partial  repositi<jn  of  the  organ  by  closing 
the  OS  externum  with  silver  sutures.  By  means  of  this  operation  the 
advance  made  at  one  sitting  is  not  lost,  and  the  case  is  thus  all  the 
better  prepared   for  future  effort. 

In  1861,  Sims  described  the  disease  kno"\^Ti  as  vaginismus,  and  recom- 
mended, as  a  means  for  its  relief,  the  removal  of  the  remains  of  the 
hymen  and  the  section  of  the  tissues  at  the  perineal  extremity  of  the 


38  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

ostium  vaginae.  This  aifection  had  been  previously  known  to  European 
authorities,  and  forcible  distension  of  the  ostium  vaginae,  together  with 
alterative  applications  with  a  view  to  the  modification  of  the  local 
nervous  hypersesthesia,  recommended  for  its  relief.  The  operation  pro- 
posed by  Dr.  Sims  was,  however,  an  advance  on  the  latter. 

Prior  to  1862  but  one  case  of  pelvic  hsematocele  had  been  published. 
In  this  year  this  subject  was  brought  prominently  to  the  notice  of  the 
profession  by  the  appearance  of  three  essays,  written  respectively  by 
John  Byrne  of  Brooklyn,  Fordyce  Barker  and  Emil  Noeggerath  of 
New  York. 

In  1866  appeared  an  excellent  treatise  on  "  Vesico-vaginal  Fistula," 
by  M.  Schuppert  of  New  Orleans.  It  contained  the  history  and 
exhaustive  summary  of  the  operation,  was  illustrated,  and  embodied 
the  extensive .  experience  of  a  successful  operator  in  this  department 
of  surgery. 

Dr.  Theophilus  Parvin  reported  in  1867  a  case  of  uretro-vaginal 
fistula  in  which  he  operated  by  turning  the  displaced  distal  extremity 
of  the  ureter  into  the  bladder,  and  then  closing  the  vaginal  opening. 
The  operation  proved  entirely  successful,  and  was  original  with  Dr. 
Parvin. 

In  1869,  H.  P.  Storer  published  a  "Method  of  Exploring  and  Ope- 
rating upon  the  Female  Rectum  by  Eversion  of  the  Anterior  Rectal 
Wall  by  a  Finger  in  the  Vagina."  Since  then  this  "  method "  has 
been  quite  generally  adopted  by  gynecologists  in  certain  cases. 

In  the  same  year  V.  A.  Taliaferro  of  Georgia  published  an  essay 
on  "  Pathological  Sympathies  of  the  Uterus,"  which  attracted  some 
attention. 

In  1869,  Dr.  Julius  F.  Miner  of  Buifalo  recommended,  as  an 
improvement  in  the  management  of  the  pedicle  after  the  removal  of 
an  ovarian  tumor,  the  stripping  off  from  the  tumor  the  expansion  of 
the  pedicle  instead  of  ligating  and  severing  it.  This  mode  of  treat- 
ing the  pedicle  was  called  by  Miner  "  enucleating  the  pedicle."  This 
method  is  applicable  in  many  cases,  and  when  it  can  be  applied  is 
much  to  be  preferred  to  the  ordinary  methods  of  securing  the  pedicle 
by  clamp  or  ligature. 

In  1870,  Dr.  T.  Gaillard  Thomas  of  New  York  removed  an  ovarian 
cyst  of  the  size  of  a  large  orange  through  an  opening  made  through  the 
vagina  and  the  cul-de-sac  of  Douglas.  This  was  the  first  time  that  this 
procedure  had  been  deliberately  adopted  for  this  purpose.  It  has  been 
successfully  practised  since  by  Dr.  Davis  of  Pennsylvania,  Dr.  Gilmour 
of  Alabama,  Dr.  Battey  of  Georgia,  and  others.  In  the  same  year  an 
important  contribution  to  the  current  gynecological  literature  appeared 
from  the  ready  pen  of  H.  R.  Storer  entitled  "  Anal  Fissure  in  Women." 
In  the  same  year  appeared  an  article  entitled  "  Sudden  Enlargement  of 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  39 

Ovarian  (_'vst.s  from  llt'm()rrliajj;e  into  them,"  by  the  late  brilliant  and 
lamcntecl  John  8.  Parrv,  who  afterward  (187G)  wrote  so  learnedly  and 
exhaustively  on  "  E.\ti'a-iitei-ine  Preii'nancy."  Dr.  F.  D.  Lente  has 
made  many  valuable  contributions  to  gyneeologieal  literature,  his  prin- 
cipal article  being  "  Intra-uteriue  Medication"  (1870),  of  which  he  was 
a  prominent  advocate.  Lente's  silver  probe  and  platinum  cup  were 
devised  tor  the  purpose  of  applying  fusible  substances,  more  particu- 
larly nitrate  of  silver,  to  the  uterine  cavity.  His  method  was  a 
marked  improvement  upcjn  many  of  the  other  modes  of  intra-uterine 
medication.  It  was  considered  very  valuable  when  caustics  were  more 
freely  and  more  frequently  used  within  the  cavity  of  the  uterus  than  is 
customary  at  the  present  time. 

In  1871,  through  the  energetic  efforts  of  Dr.  A.  Reeves  Jackson,  the 
Woman's  Hospital  of  the  State  of  Illinois  was  founded.  For  a  number 
of  years  he  was  the  surgeon-in-chief,  but  latterly  a  full  staff  of  medical 
officers  has  been  in  charge.  Dr.  M.  S.  Buttles  claims  to  have  been  the  first 
(1871)  to  apply  the  actual  cautery  to  the  uterine  cavity  in  the  treatment 
of  submucous  fibroids,  and  to  be,  therefore,  the  originator  of  that 
operation. 

In  1872,  Dr.  Robert  Battey  of  Atlanta,  Ga.,  reported  a  case  of  extir- 
pation of  the  ovaries,  the  results  of  which  justified  him  in  recommend- 
ing this  operation  for  the  relief  of  dysmenorrhoea  due  to  imperfect 
ovulation  and  accompanied  by  an  excessive  menstrual  molimen,  the 
object  of  the  operation  being  to  establish  at  once  the  change  of  life,  and 
thus  prove  an  effectual  remedy  for  diseases  otherwise  incurable  and 
dependent  upon  ovarian  irritation.  He  termed  the  operation  "  normal 
ovariotomy."  This  name  is  not  strictly  applicable,  inasmuch  as  it 
implies  a  normal  condition  of  the  ovaries,  and  is  thus  nothing  more  or 
less  than  spaying — an  operation  which  has  been  practised  from  time 
immemorial  for  the  production  of  sterility.  The  important  points  con- 
nected with  this  subject  are  best  described  in  Dr.  Battey 's  o\\u  words : 
"  I  have  operated  in  widely  different  circumstances.  In  one  case  the 
patient  had  amenorrhoea,  convulsions,  recurrent  hpematocele,  repeated 
pelvic  abscesses,  incipient  tuberculosis  from  pulmonar}^  congestion,  etc. 
Several  of  the  cases  passed  under  the  head  of  ovarian  neuralgia  ;  several 
had  intractable  dysmenorrhoea  with  pelvic  deposits  of  old  lymph ;  one 
had  ovarian  insanity,  etc.  All  had  exhausted  the  available  resources 
to  no  useful  purpose.  I  operate  upon  no  case  that  any  other  respectable 
medical  man  proposes  to  cure.  In  most  of  my  cases  the  full  results 
of  the  operation  have  not  yet  been  developed.  This  is  the  work  of 
many  months,  and  sometimes  two  or  three  years  are  necessary  to  its 
full  and  perfect  realization.  In  no  case  has  the  patient  failed  to  realize 
such  a  degree  of  relief  and  benefit  following  the  operation  as  to  amply 
compensate  her  for  the  pains  and  dangers   incident  thereto,  to   say 


40  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

nothing  of  the  promise  of  full  and  ample  recovery  at  the  completion  of 
the  physiological  change.  In  two  of  my  cases  this  change  has  seemed 
to  occur  at  once  in  all  its  comjileteness,  but  it  is  always  my  expectation 
that  it  will  occur  gradually,  extending  through  two  or  even  three  years 
to  its  final  completion.  In  my  first  case,  now  nearly  three  years  ago, 
the  restoration  to  health  is  eminently  satisfactory.  It  is  true  that  she 
is  not  absolutely  and  perfectly  well,  but  she  is  fully  relieved  of  the  con- 
vulsions, the  ovarian  periodical  congestions,  the  hsematoceles,  the  pelvic 
abscesses,  etc.  for  which  I  operated.  I  submit  the  question  in  all  sin- 
cerity :  If  I  confine  myself  to  cases  where  life  is  in  danger  or  where 
health  and  happiness  are  destroyed — cases  which  are  utterly  hopeless 
of  other  remedy  this  side  of  the  grave — ought  the  profession  to  demand 
at  my  hands  the  restoration  of  these  forlorn  invalids  to  complete  and 
absolute  health  in  every  particular?" 

The  operation  was  originally  performed  by  Dr.  Battey  in  most  cases 
with  the  patient  on  the  left  side  and  by  the  aid  of  Sims's  speculum. 
"  The  cervix  was  drawn  down  to  the  pubes  by  means  of  a  strong  hook, 
where  it  was  held  while  Douglas's  cul-de-sac  was  opened  from  the  vagina, 
by  means  of  a  pair  of  scissors.  On  reaching  the  ovary  with  the  finger 
as  a  guide  it  was  seized  by  forceps  or  tenaculum  and  drawn  into  the 
vagina.  It  was  then  separated  by  the  ^craseur,  or,  being  secured  by 
a  silk  ligature,  it  was  cut  oiF  and  the  stump  returned  into  the  cavity, 
the  opening  being  left  to  close  gradually,  so  as  to  admit  of  drainage." 
Dr.  Battey  does  not,  however,  confine  himself  to  this  method  of  opera- 
tion, but  removes  the  ovaries  by  abdominal  section  as  well.  Battey's 
operation  has  been  successfully  performed  by  a  number  of  practitioners 
since  his  introduction  of  it,  and  a  sufficient  time  has  now  elapsed  to 
permit  a  just  estimate  of  its  merits ;  and  there  no  longer  remains  any 
doubt  as  to  the  propriety  of  its  performance  in  cases  which  have  resisted 
all  other  means  of  treatment.  The  principal  danger  consists  in  its 
performance  at  the  hands  of  unskilled  persons,  and  in  the  improper 
selection  of  cases,  which  is  very  apt  to  occur  in  the  practice  of  those 
of  limited  experience  in  the  treatment  of  diseases  peculiar  to  women. 
Dr.  Sims's  inferences  from  his  experience  in  the  performance  of  the 
operation  are  as  follows,  and  they  are  generally  endorsed  by  those 
qualified  to  pass  an  opinion  :  "  1st.  Remove  both  ovaries  in  every  case; 
2d.  As  a  rule  operate  by  abdominal  section,  because  if  the  ovaries  are 
bound  down  by  adhesions  it  is  possible  to  remove  them  entire,  whereas 
by  vaginal  incision  it  is  not  possible ;  3d.  If  we  are  sure  that  there  has 
been  no  pelvic  inflammation,  no  cellulitis,  no  hsematocele,  no  adhesions 
of  the  ovaries  to  the  neighboring  parts,  then  the  operation  may  be  made 
through  the  vagina  or  otherwise."  Dr.  Goodell  of  Philadelphia  formerly 
preferred  the  vaginal  method,  and  if  he  found  it  impossible  to  remove 
the  ovaries  in  that  direction  on  account  of  adhesions  or  other  causes,  he 


IIISTOIilCAL  SKF.TCII   OF  AMElllCAN  GYNECOLOay.  41 

woukl  rosort  to  t\\v  alMloiiiiiial  .section,  Icuvini;  the  Vii<i;iiial  incision  I'oi' 
(Ici'p  (lniina<;('.  The  timely  \varnin<5  of"  tlie  experiencctl  gyncolot>,'i,st  u  iio 
ori*;-inatc(l  it  innst  never  be  forgotten  by  those  who  essay  the  proceihire. 
Dr.  Emmet  wonkl  limit  the  operation  to  the  cxtir])ation  of  Ixjth  ovaries 
for  the  arrest  of  hemorrha<;'e  from  a  fibrous  tumor  and  in  cases  of  threat- 
ened insanitv,  ejiilepsy,  or  j)hthisis.  For  nervous  disturbances  which 
j)rescnt  more  of  tlie  iiysterical  element  he  maintains  that  th(!  <jj)eration 
should  never  be  th()ui:;ht  of.  The  operation,  he  thinks,  may  be  more  fre- 
quently necessary  in  the  present  generation  than  it  ought  to  be  in  the 
future,  since  a  large  number  of  cases  calling  for  it  have,  under  inju- 
dicious management,  been  already  rendered  incurable  by  other  means. 
He  holds  that  in  the  future  this  ought  not  to  be  so,  for  our  enlarged 
opportunities  for  acquiring  skill  in  the  treatment  of  uterine  and  ovarian 
diseases  ought  to  enable  us  to  raise  our  patients  above  the  necessity  of 
such  a  terrible  ordeal.  This  operation  has  of  late  come  into  very  gen- 
eral use,  and  has  been  performed  by  many  operators  both  at  home  and 
abroad. 

During  the  year  1873  was  published  the  eminently  practical  treatise 
of  Dr.  D.  Hayes  Agnew  of  Philadelphia  on  "  Laceration  of  the  Female 
Perineum  and  Vesico- vaginal  Fistula,  History  and  Treatment."  The 
profession  is  much  indebted  to  this  author  for  his  earnest  and  valuable 
labors  in  the  branches  of  surgery  of  which  this  volume  treats. 

In  the  year  above  mentioned  was  published  by  the  Government  a 
quarto  volume  entitled  A  Report  of  the  Columbia  Hospital  for  Women. 
This  was  written  by  Dr.  J.  H.  Thompson,  the  surgeon-in-chief  of  the 
hospital.  The  book  was  very  widely  distributed  throughout  the  coun- 
try. It  contains  much  valuable  matter,  but  it  encountered  a  great  deal 
of  adverse  criticism  on  the  part  of  medical  editors  and  reviewers  fol- 
lowing its  publication. 

In  1873,  Dr.  John  Ball  of  Brooklyn  described  a  plan  of  treating 
constrictions  and  irregularities  of  the  canal  of  the  cervix  uteri  from 
flexions  and  versions  by  rapid  dilatation  by  expanding  instruments  of 
steel.  His  method  is  to  first  evacuate  the  bowels  very  thoroughly,  so  as 
to  prevent  all  effort  in  that  direction  for  two  or  three  days.  The  patient 
is  then  placed  on  her  back  with  her  hips  near  the  edge  of  the  bed 
and  profoundly  anaesthetized.  A  three-bladed,  self-retaining  speculum 
is  introduced  to  bring  the  os  uteri  into  full  view.  The  os  is  then 
seized  with  a  double-hook  tenaculum  and  drawn  toward  the  vulva, 
when  an  ample  bougie,  as  large  as  the  canal  will  admit,  is  introduced, 
and  followed  in  rapid  succession  by  others  until  tlie  canal  is  dilated  to 
admit  of  a  Xo.  7,  which  represents  the  size  of  his  dilator.  With  this 
instrument  the  cervix  is  stretched  in  every  direction  until  it  is  enlarged 
sufficiently  to  admit  of  a  No.  16  bougie.  A  hollow  gum-elastic  uterine 
pessary  of  that  size  is  then  introduced,  and  retained  in  position  by  a 


42  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

stem  secured  outside  of  the  vulva  for  about  a  week,  in  which  time  it 
will  have  done  its  work  and  is  ready  to  be  removed.  The  patient  dur- 
ing this  time  is  kept  perfectly  quiet,  usually  upon  her  back,  which  is 
generally  found  to  be  the  most  comfortable  position.  Out  of  between 
twenty  and  thirty  cases  in  which  Dr.  Ball  had  to  resort  to  this  pro- 
cedure he  has  met  with  but  one  fatal  issue.  Lately,  Dr.  Goodell  of 
Philadelphia  has  published  a  large  number  of  cases  operated  on  by 
forcible  divulsion  with  very  gratifying  results.  The  method  has  come 
into  very  general  use. 

Early  in  this  year  Emmet  published  an  account  of  the  cause  of  fail- 
ure and  a  new  mode  of  operating  for  complete  laceration  of  the  peri- 
neum. Heretofore,  operators  had  not  taken  into  account  the  fact  that 
the  muscular  fibres  of  the  sphincter  retract  more  than  the  others.  Con- 
sequently, only  the  external  fibres  were  brought  together,  resulting 
often  in  entire  or  partial  failure  to  restore  the  retentive  powers  of  the 
anus,  and  frequently,  while  the  external  parts  would  be  united  and  the 
operator  thought  he  had  been  successful,  it  was  common  to  find  that  a  fis- 
tula resulted.  By  diagrams  and  descriptions  he  showed  in  his  written 
articles  the  manner  in  which  the  denudation  must  be  made  and  sutures 
placed  in  order  to  secure  apposition  of  the  inner  as  well  as  the  outer 
fibres  of  the  sphincter :  "  If  we  examine  careftilly  the  extremities  of 
the  lacerated  muscle,  we  shall  find  a  slight  pit  or  depression  at  each  end 
which  has  been  caused  by  contraction  of  a  portion  of  its  fibres.  At  the 
commencement  of  the  operation  a  portion  of  the  tissues  at  this  point 
must  be  seized  with  a  tenaculum  and  removed  with  a  pair  of  scissors, 
together  with  a  narro^v  strip  entirely  around  the  laceration  to  the  oppo- 
site end  of  the  muscle.  After  the  edges  of  the  muscles  have  been  prop- 
erly denuded  the  most  important  part  of  the  operation  is  to  introduce 
the  first  suture  in  its  proper  relation  to  the  edges  of  the  divided  muscle. 
The  manner  in  which  these  sutures  should  be  introduced  can  only  be 
shown  by  diagrams,  and  is  not  essential  in  this  connection.  These 
sutures  are  so  adjusted  that  the  divided  edges  of  the  sphincter  are 
turned  up  and  appear  in  perfect  apposition." 

But  he  also  taught  the  profession  the  importance  of  adjusting  the 
sutures  in  order  to  make  this  operation  a  success ;  and  as  a  result  of 
the  teachings  of  this  distinguished  gynecologist  his  mode  of  operating  in 
these  cases  has  become  generally  known,  and  is  now  the  common  prop- 
erty of  the  profession.  In  his  very  latest  writings  he  announces  that  he 
has  but  little  to  add  as  the  result  of  further  experience  to  the  paper 
which  was  published  during  this  year.  He  states  that  to  unravel  the 
cause  of  failure  in  this  operation  and  to  devise  means  of  obviating  it 
have  occupied  his  attention  for  many  years,  and  that  they  have  cost 
him  more  thought  than  he  has  ever  devoted  to  any  other  professional 
subject. 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  43 

In  IST.")  nlso  \)r.  'I'lidiims  M.  Drysilalc  of  IMiilndclpliia  described  a 
j)0('uliar  {•orpiisck'  as  characteristic  of  ovarian  lliiid,  and  i'or  a  time  it 
was  believed  that  a  [)erl"ect  means  of  diagnosis  of  the  existence  of  cystic 
ovarian  tumors  by  microscopical  examination  of  their  contents  could 
be  tleterniined  ;  but  while  Dr.  Drysdale  se;'ms  to  have  been  very  suc- 
cessful in  diaj;'uosticatiug-  ovarian  tumors,  others  have  not  been  so  suc- 
cessful. 'Pile  late  Dr.  Atlee  attached  great  importtmce  to  this  method 
of  Dr.  Drvsdale's,  whose  views  U])on  this  matter  may  be  sunuued  uj)  in 
the  fallowing  words  :  "  I  claim,  then,  that  a  granular  cell  has  been  dis- 
covered by  me  in  ovarian  fluid  which  differs  in  its  behavior  with  acetic 
acid  and  ether  from  any  other  known  granular  cell  found  in  the  abdom- 
inal cavity,  antl  which  by  means  of  these  reagents  can  be  readily  recog- 
nized as  the  cell  which  has  been  described ;  and  further,  that  by  the 
use  of  the  microscope  and  assisted  by  these  tests  we  may  distinguish 
the  fluid  removed  from  ovarian  cysts  from  other  abdominal  dropsical 
fluids." 

In  this  same  year  (1873)  a  paper  which  has  been  designated  as  a 
remarkable  one,  and  which  excited  much  adverse  criticism,  was  pub- 
lished by  Joseph  R.  Beck  of  Indiana,  entitled  "  How  did  the  Sperma- 
tozoa Enter  the  Uterus  ?"  The  patient  of  the  doctor  in  whom  sexual 
orgasm  could  be  produced  by  digital  examination  was  the  subject  upon 
whom  his  observations  were  made,  which  are  reported  as  follow^s  :  "  The 
cervix  uteri  had  been  firm,  hard,  and  generally  in  a  normal  condition, 
with  the  OS  closed  so  as  not  to  admit  the  uterine  probe  without  difficulty ; 
but  immediately  the  os  opened  to  the  extent  of  fully  an  inch,  made  five 
or  six  successive  gasps,  drawing  the  external  os  into  the  cervix  each 
time  powerfully,  and  at  the  same  time  becoming  quite  soft  to  the  touch. 
All  these  phenomena  occurred  within  the  space  of  twelve  seconds'  time 
certainly,  and  in  an  instant  all  'svas  as  before — the  os  was  closed,  the 
cervix  hardened,  and  the  relation  of  the  parts  had  become  as  before  the 
orgasm."  According  to  Flint,  Jr.,  Sitzmann  of  Germany  published 
similar  observations  in  1846. 

In  1874  one  of  the  most  important  contributions  to  the  pathology 
and  treatment  of  diseases  of  the  neck  of  the  uterus  was  published  by 
Dr.  T.  Addis  Emmet.  It  had  long  been  known  that  childbirth  caused 
lacerations  of  the  muscular  portion  of  the  neck  of  the  uterus,  but  pre- 
vious to  his  description  no  one  had  seemed  to  recognize  how  uniformly 
such  lacerations  had  been  confounded  with  so-called  ulceration  of  the  neck 
of  the  uterus,  or  how  commonly  the  ectropion  at  the  neck  of  the  lip 
resulting  from  such  tears  had  been  mistaken  for  hypertrophy  of  the 
tissues.  Emmet,  recognizing  these  conditions,  began  to  devise  some 
method  for  their  cure,  and  he  advocated  for  this  condition  the  paring 
of  the  edges  of  the  ulcerated  part  and  the  bringing  of  them  together 
bv  means  of  sutures. 


44  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

The  mode  of  operating,  as  first  laid  down  by  Emmet,  is  to  place  the 
patient  on  the  left  side,  in  the  Sims  position,  and  by  means  of  a  Sims 
speculum  bring  the  parts  into  view.  Tlie  first  step  is  to  bring  the  flaps 
together  in  apposition,  and  while  they  are  lifted  up  by  means  of  a  double 
tenaculum  in  the  hands  of  an  assistant  a  uterine  tourniquet  is  slipped 
over  the  cervix  below  the  point  of  vaginal  junction,  and  tightened, 
the  object  of  this  being  to  control  hemorrhage  during  the  operation. 
The  surfaces  of  the  laceration  are  then  freshened  either  with  scissors 
or  scalpel,  after  which  they  are  brought  together  by  means  of  silver 
sutures.  One  of  the  essentials  to  the  success  of  the  operation  consists 
in  the  complete  removal  of  cicatricial  or  other  adventitious  tissue  during 
the  freshening  of  the  parts. 

Since  the  introduction  of  Emmet's  operation  and  the  publication 
by  its  author  of  the  technique  of  the  operation,  other  gynecologists 
have  adopted  different  means  to  accomplish  the  same  results.  The 
uterine  tourniquet  is  not  deemed  requisite  to  control  hemorrhage,  nor 
is  it  the  universal  custom  to  place  the  patient  in  either  the  left  or  right 
semi-prone  position.  It  is  no  longer  deemed  a  prerequisite  to  success 
that  silver  wire  must  be  invariably  used,  or  that  no  other  speculum 
than  Sims's  will  suffice.  Hot  water  will  control  hemorrhage.  The 
dorsal— or,  more  commonly,  the  exaggerated  lithotomy  position,  or 
the  position  of  Simon — is  chosen  by  many.  Silk,  or  catgut  properly 
prepared,  is  more  easily  introduced  than  silver,  and  is  less  liable  to 
cut  tissues.  The  silkworm-gut  suture  is  preferred  by  some.  Some 
of  those  who  have  used  Simon's  speculum  a  number  of  times  prefer 
it  to  Sims's.  This  procedure  is  now  generally  known  as  "  Emmet's 
operation."  It  is  the  belief  of  most  American  gynecologists — in 
which  the  writer  fully  concurs — that  this  operation  marks  one  of  the 
greatest  advances  in  modern  gynecology.  At  the  same  time,  it  is  an 
operation  which  is  liable  to  many  and  great  abuses.  Owing  to  the  fact 
that  so  many  neurasthenic  women,  as  well  as  those  suffering  from  neur- 
algias from  the  imprisonment  of  nervules  in  the  cicatricial  tissue  of  the 
torn  uterine  neck,  have  been  relieved  by  this  operation,  many  superficial 
observers  have  resorted  to  it  with  such  frequency  as  to  often  bring  it  into 
disrepute.  Many  of  our  foreign  brethren  have  also  attempted  to  ridi- 
cule the  operation,  but,  in  spite  of  all,  the  fact  still  remains  that  no  one 
operation  or  procedure  of  equal  importance  for  the  relief  of  suffering 
women  has  been  devised  in  the  last  quarter  of  a  century. 

In  March  of  this  same  year  (1874)  Emmet,  during  an  operation  for 
a  submucous  fibroid  tumor  of  the  uterus,  discovered  the  value  of  trac- 
tion during  enucleation  in  producing  a  denuded  pedicle.  His  mode 
of  operating  was  with  scissors  around  the  base  of  the  tumor,  and  to  his 
surprise  the  raw  surface  thus  left  seemed  much  smaller  than  the  orig- 
inal base  of  the  tumor.     The  value  of  traction  was  several  years  before 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  45 

insisted  upon  by  him,  but  not  until  Mai-ch,  1874,  was  he  able  to 
demonstrate  clearly  that  the  attenuated  pedicle  was  the  eif'ect  of  the 
traction,  and  not  an  accident.  In  a  case  operated  upon  at  that  time  he 
was  able  to  encircle  the  broad  basis  of  the  tumor  with  his  lingers  and 
feel  tlie  process  of  pedunculation  fj^oinj^  on,  as  strong  contraction  was 
produced  bv  traction,  the  contraction  beginning  at  the  fundus  and  run- 
ning down  in  an  oblique  direction.  On  this  account  the  traction  should 
be  made  as  near  the  fundus  as  possible.  In  this  case  a  base  of  three 
inches  in  diameter  became  a  pedicle  of  the  size  of  a  common  lead-pencil, 
and  the  point  of  attachment  after  removal  was  reduced  to  a  small  pit, 
thus  leaving  an  almost  infinitesimal  surface,  comparatively  speaking, 
for  the  possible  absorption  of  septic  matter. 

In  the  year  1874  there  were  two  papers  in  the  Boston  Medical  Jour- 
nal upon  pelvic  drainage  after  ovariotomy,  by  Dr.  Gilman  Kimball  of 
Lowell,  Mass.,  a  distinguished  pioneer  in  ovariotomy.  Dr.  Montrose 
A.  Fallen  of  New  York  published  a  description  of  the  operation  as  a 
substitute  for  amputation  of  the  neck  of  the  uterus  in  certain  forms  of 
intravaginal  elongation,  which  he  termed  vaginal  cervi  plasti. 

In  the  same  year  Dr.  Marion  Sims  contributed  a  valuable  paper  to 
the  JVew  York  Medical  Journal  upon  the  enucleation  of  intra-uterine 
fibroids. 

In  this  year  also  appeared  a  small  work,  written  in  a  powerful  style 
by  Dr.  Edward  H.  Clark  of  Boston,  entitled  Sex  in  Education.  No 
work  upon  medical  topics  or  any  kindred  subject  in  modern  times  suc- 
ceeded better  in  attracting  the  attention  of  the  people  for  whose  benefit 
it  was  written  to  the  influence  of  the  habits  of  modern  life  on  the 
sexual  organs. 

In  1875  a  valuable  and  interesting  paper  appeared  by  Dr.  J.  R. 
Chad  wick  of  Boston  in  the  American  Journal  of  Obstetrics  upon  injec- 
tion of  nutritious  or  cathartic  fluid  into  the  intestines  through  the 
abdominal  walls  by  means  of  an  aspirator  needle  when  the  stomach 
proves  entirely  intolerant. 

In  this  year  Dr.  Noeggerath  of  New  York  published  in  the  Ameri- 
can Journal  of  Obstetrics  an  interesting  paper  upon  "  Vesico- vaginal 
and  Vesico-reetal  Touch — a  New  Method  of  Examining  the  Uterus 
and  Appendages." 

In  the  Transactions  for  1875  of  the  American  Medical  Association 
is  a  paper  by  Dr.  Byford  of  Chicago  upon  "  The  Treatment  of  Uterine 
Fibroids  by  Ergot."  This  method,  for  the  purpose  of  causing  atrophy 
of  uterine  fibroids,  was  first  suggested  by  Hildebrandt,  but  Byfoi'd  seems 
to  have  been  the  first  to  advocate  the  use  of  this  remedy  in  sufficiently 
large  doses  to  cause  expulsion  in  addition  to  the  atrophy. 

In  this  same  year  was  published  a  valuable  and  very  interesting 
paper  by  Dr.  H.  F.  Campbell  of  Georgia  upon  "  Position,  Pneumatic 


46  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

Pressure,  and  Mechanical  Appliance  in  Uterine  Displacements."  This 
gentleman  has  from  time  to  time  written  several  papers  bearing  upon 
the  same  subject.  He  advocated  replacement  of  uteri,  if  posteriorly 
displaced,  by  the  patient  assuming  the  knee-chest  position,  and  the 
introduction  of  a  glass  tube  into  the  vagina  while  this  jDOsition  is 
maintained.  This  position,  by  favoring  the  gravitation  of  the  viscera 
forward,  together  with  the  introduction  of  air  into  the  vagina  through 
the  glass  tube,  will  often  effect  reposition  of  the  displaced  organ. 

In  this  same  year  an  interesting  paper  was  contributed  to  iYie  Rich- 
mond and  Louisville  Medical  Journal  by  Dr.  Goodman  of  Louisville 
upon  ""  Menstruation  and  the  Law  of  Monthly  Periodicity."  Dr. 
Brickell  of  New  Orleans  contributed  also  an  article  upon  "  Rupture 
of  the  Perineum,  with  a  Description  of  a  New  Operation." 

In  1875,  Alexander  Skene  of  Brooklyn  performed  the  operation  of 
laparo-elytrotomy,  with  a  result  never  before  attained.  The  patient  was 
a  dwarf  with  a  rachitic  pelvis,  who  had  been  three  times  delivered — 
twice  by  premature  delivery  and  once  by  craniotomy.  In  her  fourth 
pregnancy  Dr.  Skene  allowed  it  to  advance  to  the  full  term,  and  then, 
after  labor  had  begun,  he  performed  the  operation,  saving  the  mother 
and  a  healthy  child  of  ten  pounds'  weight.  This  operation  might  more 
properly  be  designated  as  one  pertaining  to  obstetrics,  and  yet  we  cannot 
forbear  alluding  to  it  here.  It  is  one  that  had  attracted  the  attention 
of  obstetricians  in  our  own  country  and  in  Europe  at  different  times, 
and  had  been  essayed  by  Skene  in  1874,  but  first  by  T.  Gaillard 
Thomas  in  1870,  who  states  that  he  did  it  without  a  knowledge  of  the 
fact  that  he  been  anticipated  in  the  procedure  by  Baudeloque.  In  Dr. 
Thomas's  case  the  patient  died  in  one  hour,  and  the  child,  premature 
and  imperfectly  developed,  also  almost  simultaneously. 

The  year  1876,  being  termed  the  "Centennial  year,"  as  it  was  the 
year  in  which  this  country  celebrated  its  hundredth  anniversary  as  an 
independent  nation,  was  rich  in  gynecological  work.  It  also  marks 
the  beginning  of  a  very  important  epoch  in  American  gynecology — 
namely,  the  formation  of  the  American  Gynecological  Society.  In 
response  to  a  summons  issued  May  24th  a  number  of  gynecologists 
from  various  parts  of  the  United  States  came  together  at  the  hall  of 
the  Academy  of  Medicine  in  the  city  of  New  York  for  the  purpose  of 
forming  a  society  for  the  advancement  of  the  special  department  of 
medicine  in  which  they  were  chiefly  interested.  The  meeting  was 
called  to  order  by  Dr.  Chadwick  of  Boston,  who  had  taken  the  most 
active  part  in  the  formation  of  the  society,  and  was  organized  by  the 
election  of  Dr.  E.  R.  Peaslee  of  New  York  as  chairman  and  Dr. 
Chadwick  as  clerk.  Remarks  was  made  by  Dr.  Peaslee  upon  the 
importance  of  such  a  society,  and  by  Dr.  Chadwick,  who  said  that 
"  the  call  to  which  vou  have  responded  by  your  presence  here  to-day 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  47 

was  acklrossod  to  a  liiuitcd  miinlKT  of  rwoi^iiizeil  fi;vnc('()l()<>i.st.s  after 
consultation  witli  several  of  the  [)r(>niinent  men  of  IJoston,  xSew  York, 
riiihulelpliia,  and  the  West.  It  was  not  intended  to  include  all  those 
whose  labors  in  this  field  of  medicine  would  fully  entitle  them  to  an 
honored  place  in  our  ranks,  but  simply  to  form  a  nucleus  around  which 
o'vnecologists  of  the  country  should  cliLstcr.  It  seems  a  most  fitting 
tribute  to  our  national  <>reatness  that  those  who  have  striven  to  advance 
the  noble  cause  of  humanity,  of  science,  of  art  in  any  of  their  depart- 
ments should  take  ste[)s  in  this  Centennial  year  to  prosecute  their  labors 
in  the  coming  century  with  reucAved  vigor  and  under  more  favorable 
circumstances."  These  remarks  apply  with  more  than  common  force 
to  the  branch  of  medicine  in  which  America  can  justly  claim  to  stand 
pre-eminent.  Tiiere  were  at  this  inaugural  meeting  the  following  gen- 
tlemen :  Drs.  Fordyce  Barker,  E.  R.  Peaslee,  T.  A.  Emmet,  T.  G. 
Thomas,  J.  M.  Sims,  I.  E.  Taylor,  E.  Noeggerath,  W.  T.  Lusk,  P. 
F.  Munde,  of  New  York ;  John  Bvrne,  A.  J.  C.  Skene,  of  Brooklyn ; 
A.  D.  Sinclair,  G.  H.  Bixby,  J.  R.'Chadwick,  of  Boston;  W.  Goodell 
of  Philadelphia;  J.  D.  Trask  of  Astoria,  N.  Y.;  T.  Parvin  of  Indian- 
apolis ;  W.  H.  Byford  of  Chicago ;  and  Ed.  W.  Jenks  of  Detroit,  Mich. 

Letters  were  read  from  Drs.  D.  H.  Storer,  C.  E.  Buckingham,  G. 
H.  Lyman,  AV.  L.  Richardson,  of  Boston ;  W.  L.  Atlee,  R.  A.  F. 
Penrose,  E.  Wallace,  A.  H.  Smith,  T.  M.  Drysdale,  J.  Y.  Ingham, 
of  Philadelphia ;  S.  C.  Busey  of  Washington ;  E.  Van  de  Warker 
of  Syracuse ;  J.  P.  White,  of  Buffalo ;  R.  Battey,  of  Rome,  Ga. ; 
J.  C.  Reeve,  of  Dayton,  O. ;  and  G.  J.  Engelmann,  of  St.  Louis.  On 
motion  these  gentlemen  were  added  to  the  list  of  Fellows,  and  were 
considered  as  founders  of  the  society. 

A  committee  consisting  of  Drs.  Trask,  Sinclair,  Jenks,  Noeggerath, 
and  Lusk  Avas  appointed  by  the  chair  to  nominate  a  list  of  officers  for 
the  first  annual  meeting.  The  following  list  of  officers  was  reported, 
and  the  gentlemen  unanimously  elected :  President,  Fordyce  Barker ; 
Vice-Presidents,  W.  L.  Atlee,  W.  H.  Byford  ;  Council,  J.  M.  Sims,  W. 
Goodell,  T.  Parvin,  G.  H.  Lyman;  Secretary,  J.  R.  Chadwick;  Treas- 
urer, P.  F.  Mund6. 

The  first  annual  meeting  of  the  society  was  held  in  the  same  place 
Sept.  13,  14,  and  15,  1876,  at  which  twenty-eight  Fellows  were  pres- 
ent. This  society  has  since  its  organization,  although  not  numbering 
among  its  Fellows  all  of  the  able  gynecologists  of  our  country,  reallv 
represented  the  progress  of  American  gynecology.  Its  annual  volumes 
of  Transactions  have  shown  the  rapid  progress  made  in  this  specialty, 
and  have  given  evidence  of  much  original  work,  and  each  year  its  list 
of  Fellows  has  been  augmented  by  the  election  of  new  members,  and, 
although  many  of  its  founders  have  passed  away,  the  character  of  the 
societs^'s  work  has  continued  to  be  of  the  highest. 


48  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

Dr.  Lyman  of  Boston  published  a  paper  on  the  theory  entitled  "  A 
Theory  of  the  Cause  of  Menorrhagia/'  with  a  list  of  cases  treated  with 
success  by  dilatation,  which  reads  substantially  as  follows  :  '^  Dilatation 
of  the  cervix  for  surgical  and  diagnostic  purposes  is  an  old  procedure, 
but  that  it  should  be  followed  by  arrest  of  hemorrhage,  although 
observed  by  some,  was  not  publicly  noticed  until  1869  by  Dr,  Sims." 
In  1876,  Dr.  Lyman  of  Boston  reported  a  short  list  of  cases  in  which 
he  had  used  dilatation  with  success  in  menorrhagia,  and  advanced  the 
following  theory  :  "  In  menorrhagia  there  is  constriction  of  the  vessels 
at  the  internal  os,  giving  rise  to  congestion  of  the  tissues  above :  such 
constriction  doubtless  is  due  to  some  morbid  condition  beneath  the 
mucous  membrane.  Hence  this  operation  is  beneficial,  although  the 
opening  through  the  canal  be  apparently  sufficiently  large.  Precaution 
is  to  be  taken  that  the  hemorrhage  is  not  due  to  malignant  disease,  and 
that  there  is  no  cellulitis  nor  peritonitis." 

In  this  same  year  a  valuable  paper  was  published  by  Dr.  Skene  on 
the  principles  of  gynecology  as  applied  to  obstetrical  operations. 
Although  not  wholly  original  or  the  first  time  that  many  of  his 
theories  were  enunciated,  it  is  well  worthy  of  mention  in  a  history 
of  American  gynecology.  Dr.  Skene  advocated  the  use  of  Sims's 
speculum  in  performing  craniotomy  and  in  using  the  cephalotribe, 
perforation  being  recommended  to  precede  the  use  of  that  instrument. 
The  use  of  Sims's  speculum  also  facilitates  the  carrying  out  of  Thom- 
as's method  of  replacing  a  prolapsed  cord ;  also  the  introduction  of 
Barnes's  dilators.  He  also  recommended  the  use  of  the  speculum  in 
applying  the  tampon  for  arrest  of  hemorrhage  and  in  the  use  of  the 
curette  or  the  scoop  in  removing  the  ovum. 

In  1876,  also.  Dr.  Noeggerath  of  New  York  read  a  paper  at  the 
American  Gynecological  Society  upon  latent  gonorrhoea,  especially  with 
regard  to  its  influence  on  fertility  in  woman.  This  was  his  first  paper 
in  the  English  language  upon  the  subject,  as  the  one  in  1872  was  pub- 
lished in  the  German  language  in  Bonn.  This  paper  has  given  rise  to 
much  discussion,  favorable  and  unfavorable,  and  frequent  allusion  to  it 
has  been  made  in  home  and  foreign  journals.  The  jjaper  and  the 
author's  conclusions  are  certainly  unique,  and  we  cannot  forbear  to 
allude  to  the  latter,  which  he  summarizes  as  follows : 

"  1st.  Gonorrhoea  in  the  male,  as  well  as  in  the  female,  persists  for 
life  in  certain  sections  of  the  organs  of  generation,  notwithstanding  its 
apparent  cure  in  many  instances. 

"  2d.  There  is  a  form  of  gonorrhoea  which  may  be  called  latent  gon- 
orrhoea, in  the  male  as  well  as  the  female. 

"  3d.  Latent  gonorrhoea  in  the  male,  as  well  as  in  the  female,  may 
infect  a  healthy  person  either  with  acute  gonorrhoea  or  gleet. 

"  4th,  Latent  gonorrhoea  in  the  female,  either  the  consequence  of  an 


HISTORICAL  SKETCH  OF  AM  ERICA  X  GYNECOLOGY.  49 

acute  li'onorrhti'al  invasion  (»r  not,  iC  it  j)a>scs  I'roni  tlic  latent  into  the 
apparent  condition  manifests  itself  iis  uciite,  chronic,  ro(;urrcnt  peri- 
metritis or  ovaritis,  or  catarrh  of  certain  sections  of  the  genital  or^^ans. 

*'  5th.  Latent  gonorrha'a  in  becoming  apparent  in  the  male  does  so 
by  attacks  of  gleet  or  epididymitis. 

''  Gth.  Abont  J)0  percent,  of  sterile  women  are  married  to  husbands  who 
have  suifercd  from  gonorrhoea,  j)revionsly  to  or  during  marrietl  life." 

In  187G,  Dr.  Jenks  of  Detroit  i)ublishcd  the  result  of  his  observa- 
tions ou  the  use  of  Vibunxam  pruni/oliain  in  the  treatment  of  disea-ses 
of  women.  This  remedy  had  a  limited  use  for  some  years  as  a  preven- 
tive of  abortion,  it  having  been  iirst  introduced  by  Dr.  Phares  of  Mis- 
sissippi. The  writer  advocated  the  use  of  this  remedy  in  all  forms  of 
dysmenorrhwa  attended  Avitli  profuse  menstruation.  It  is  not  sufficiently 
stnlative,  if  given  alone,  to  fully  relieve  the  sufferings  of  spasmodic 
dysmenorrJKpa.  It  is,  however,  a  valuable  adjuvant  to  sedative  and 
antispasmodic  remedies.  In  dysmenorrhoea  with  menorrhagia  caused 
by  fibroid  gro^^i:hs  viburnum,  in  combination  "with  ergot,  has  proved 
much  more  valuable  than  either  remedy  given  without  the  other.  The 
writer  gave,  as  a  general  statement  concerning  the  uses  of  viburnum, 
*'  that  it  is  serviceable  in  all  uterine  disorders  characterized  Iiy  loss  of 
blood."  Since  Dr.  Jenks's  paper  was  published  the  remedy  has  come 
into  more  general  use,  and  the  results  have  shown  that  too  much  was 
not  said  in  its  praise. 

In  this  year  also  the  first  ten  cases  of  Battey's  operation  by  Dr. 
Battey  were  published,  the  following  results  being  claimed  for  the 
operation  in  the  cases  reported :  Complete  relief,  3 ;  temporary  relief,  2  ; 
life  prolonged,  1 ;  no  benefit,  2 ;  death,  2. 

In  the  same  year  there  was  published  by  Henry  C  Lea  of  Philadel- 
phia a  small  volume  entitled  A  Century  of  American  Medicine,  Dr.  T. 
G.  Thomas  contributing  the  chapter  on  obstetrics  and  gynecology.  Xo 
one  except  those  who  have  had  occasion  to  search  through  the  volumes 
and  periodicals  for  historical  matter  can  flilly  appreciate  the  labor 
which  such  an  able  paper  must  have  cost  its  author.  It  contains  a 
summary  of  ever}i:hing  of  importance  that  had  been  previously  done 
in  these  departments  by  the  profession  of  this  country. 

In  1877  a  paper  was  published  by  Dr.  Brickell  of  Xew  Orleans  on 
the  diagnosis  and  treatment  of  pelvic  effusions.  Three  cases  are 
reported  by  Dr.  George  H.  Bixby,  one  by  Dr.  Byford,  treated  by 
aspiration  either  through  the  abdominal  walls  or  per  var/inam,  the 
latter  site  being  preferred.  The  history  of  these  cases  is  valuable  as 
showing  the  progress  in  the  diagnosis  of  pelvic  effusions  and  the  relief 
afforded  by  this  mode  of  treatment.  Dr.  Brickell  considers  the  removal 
of  a  collection  of  serum  in  the  cellular  tissue  as  necessar}'  as  the  removal 
of  a  collection  of  pus. 

Vol.  I.— 4 


50  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

A  paper  was  read  before  the  American  Gynecological  Society  by  Dr. 
Goodell  on  the  subject  of  vaginal  ovariotomy.  This  operation  was 
first  performed  by  Washington  L.  Atlee,  but  the  first  premeditated 
vaginal  ovariotomy  was,  as  previously  stated,  performed  by  Dr.  T.  G. 
Thomas  in  1870.  Dr.  Goodell,  in  discussing  the  subject,  concludes 
that  while  this  operation  can  never  rival  the  ordinary  operation,  it  is 
preferable  in  rare  cases — namely,  where  a  small  polycyst  lodges  in 
Douglas's  pouch  or  an  unadherent  monocyst  protrudes  into  the  pelvic 
cavity.  The  difficulties  met  with  in  this  operation  are  from  prolapsus 
of  the  intestines  and  unforeseen  adhesions.  In  this  same  year  Dr.  Paul 
r.  Munde  made  a  valuable  reports  on  the  treatment  of  ovarian  tumors 
by  electrolysis.  Dr.  Von  Ehrenstein  claims  to  be  the  originator  of  this 
method,  and,  although  this  claim  is  disputed,  he  has  at  least  had  a 
larger  experience  than  any  other  in  its  use.  It  was  brought  more 
prominently  into  notice  by  an  announcement  in  1875  of  Dr.  Semelleder 
of  Mexico.  Dr.  Mund^,  from  his  own  experience  and  that  of  others, 
draws  the  following  conclusions  regarding  the  operation :  That  this 
method  is  most  apt  to  be  beneficial  in  cases  where  the  tumor  is  mono- 
cystic,  and  yet  so  small  as  not  to  demand  the  radical  operation ;  or  a 
polycyst  with  thin  walls  and  fluid  contents,  and  absence  of  large  and 
solid  masses ;  or  a  large  unilocular  or  multilocular  tumor,  in  which 
adhesions  are  so  extensive  as  to  render  ovariotomy  dangerous. 

Although  it  has  long  been  known  that  mental  aberrations  may  be 
caused  by  the  sexual  disturbance  occurring  at  the  time  of  puberty, 
menopause,  during  pregnancy,  the  puerperal  state,  and  lactation,  the 
idea  of  connecting  this  abnormal  mental  state  with  disease  of  a  non- 
gravid  uterus  is  modern.  The  first  in  this  country  to  call  attention  to 
the  causative  relations  of  uterine  and  ovarian  disease  to  mental  dis- 
turbances in  women  were  Dr.  Fordyce  Barker  of  New  York  and  Dr. 
H.  R.  Storer  of  Boston.  The  former  published  an  article  upon  this 
subject  in  1872,  and  the  latter  a  monograph  upon  the  same  subject  in 
1871,  while  both  had  promulgated  their  ideas  by  lectures  some  years 
previously. 

In  1877,  Dr.  George  J.  Engelmann  made  a  valuable  collection  of 
facts  concerning  hystero-neurosis.  These  show  that  neuroses  of  the 
brain,  pharynx,  larynx,  eye,  stomach,  intestines,  bronchii,  and  joints 
of  severe  and  misleading  character  are  frequently  produced  by  non- 
development  or  disease  of  the  uterus  or  ovaries,  or  both,  or  by  peri- 
uterine disease.  That  the  apparent  disease  of  the  organs  named  was  a 
neurosis  was  proved  by  its  disappearance  upon  removal  of  the  abnor- 
mal condition  of  the  uterus. 

In  1878  there  appeared  a  paper  on  the  causes  of  vesico-vaginal  fis- 
tula by  Dr.  T.  A.  Emmet,  in  which  he  exonerated  the  forceps  from 
the  charge  that  has  been  laid  to  them  of  frequently  causing  such  lesions, 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  51 

ami  attributed  the  l'iv(|uciicy  ol'  tistiilii  rather  to  delay  in  delivery  and 
the  neglect  to  use  the  catheter  before  instrumental  delivery. 

In  this  same  year  appeared  in  the  Ncio  York  Medical  Journal  a  very 
valuable  contribution  from  tiie  facile  pen  of  Dr.  T.  G.  Thomas  on  the 
most  eti'ectual  method  for  controlling  the  high  temperature  occurring 
during  ovariotomy.  Dr.  Thomas's  method  is  as  follows  :  Upon  a 
Kibbee  fever-cot  a  folded  blanket  is  laid,  so  as  to  protect  the  patient's 
body  from  cutting  by  the  cords  of  the  netting.  At  one  end  is  placed 
a  pillow  covered  with  india-rubber  cloth,  and  a  folded  sheet  is  laid 
across  the  middle  of  the  cot  to  -about  two-thirds  of  its  extent.  Ujjon 
this  the  patient  is  now  laid :  her  clothing  is  lifted  up  to  the  armi)its 
and  the  body  enveloped  by  the  folded  sheet,  which  extends  from  the 
axillffi  to  a  little  below  the  trochanters.  The  legs  are  covered  by  flan- 
nel drawers  and  the  feet  by  warm  woollen  stockings,  and  against  the 
soles  of  the  latter  bottles  of  warm  water  are  apj^lied.  Two  blankets 
are  then  placed  over  the  patient  and  the  application  of  water  is  made. 
Turning  the  blankets  down  below  the  pelvis,  the  physician  now  takes  a 
large  pitcher  of  water  at  from  70°  to  80°  F.,  and  pours  it  gently  over  the 
sheet.  This  it  saturates,  and,  percolating  the  network  of  the  cot,  it  is 
caught  by  the  india-rubber  cloth  beneath,  and,  running  down  the  gutter 
formed  by  this,  is  received  in  a  tub  placed  at  its  extremity  for  that  pur- 
pose. Water  at  a  higher  or  lower  temperature  than  this  may  be  used. 
As  a  rule,  it  is  better  to  begin  with  a  high  temperature,  85°  to  90°,  and 
gradually  diminish  it.  The  patient  now  lies  in  a  thoroughly  soaked  sheet 
with  warm  bottles  to  her  feet,  and  is  covered  up  carefully  with  dry  blank- 
ets. Neither  the  portion  of  the  thorax  above  the  shoulders  nor  the  infe- 
rior extremities  are  wet  at  all.  The  water  is  applied  only  to  the  trunk. 
The  first  effect  of  the  affusion  is  to  elevate  the  temperature,  but  the 
next,  wdien  the  application  is  practised  for  an  hour,  usually  brings  it 
down.  The  water  collected  in  the  tub  at  the  foot  of  the  bed,  having 
passed  over  the  body,  is  usually  eight  or  ten  degrees  warmer  than 
when  poured  from  the  pitcher.  This  mode  of  procedure  has  been 
modified  by  others,  but  still  it  is  to  Dr.  Thomas  that  we  are  indebted 
for  this  effective  means  of  reducing  the  temperature. 

In  this  same  year  Dr.  E.  Van  de  Warker  of  Syracuse,  N.  Y.,  con- 
tributed a  valuable  paper  containing  some  original  opinions  upon  the 
treatment  of  adhesions  and  indurations.  The  objects  of  treatment  in 
this  case  are — 1st,  to  allay  pain  ;  2d,  to  produce  absorption.  For  the 
first  object  anodynes — namely,  opium  or  opium  combined  with  Vibur- 
num prunifolium — are  valuable.  JNIore  important,  however,  though  act- 
ing less  quickly,  are  rest,  postural  treatment,  hot  fomentations,  and  an 
occasional  blister.  Swinging  in  a  hammock  admirably  combines  a 
soothing  feeling,  from  the  gentle  motion,  with  relaxation  of  the  abdom- 
inal muscles  and  elevation  of  the  hips.     The  continuous  current,  ten 


52  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

to  sixteen  cells,  indirectly  through  the  system  and  through  the  indura- 
tion, is  also  important.  The  agents  for  producing  absorption  are  less 
direct,  but  still  more  valuable — ^viz.  the  galvanic  current  directly 
through  the  mass,  one  electrode  being  placed  in  the  vagina  and  one  on 
the  abdomen.  The  internal  us,e  of  ammonium  chloride  markedly  less- 
ens the  size  of  the  mass,  producing  absorption,  probably  by  its  eifect 
upon  the  portal  circulation.  Careful  handling  at  a  later  stage  not  only 
hastens  absorption,  but  also  tends  to  reduce  the  tenderness.  The  best 
method  is  by  bimanual  manipulation,  a  gentle  to-and-fro  motion  given 
the  mass  by  rolling  it  between  the  hands,  one  of  which  is  placed  against 
the  vaginal  and  the  other  against  the  abdominal  side.  If  the  mass  is 
situated  in  the  iliac  fossa,  then  the  bone  aifords  sufficient  internal  sup- 
port, and  but  one  hand  is  used. 

In  1878,  Dr.  Henry  J.  Bigelow  of  Boston  reported  a  number  of 
cases  operated  upon  by  a  method  which  he  had  devised  for  crush- 
ing and  removing  the  fragments  of  stone  in  the  male  bladder.  He 
demonstrated  that  tolerance  by  the  bladder  of  protracted  manipula- 
tion is  greater  than  heretofore  recognized,  and  that  the  operation  of 
lithotrity  can  be  done  at  one  sitting.  The  article  of  Dr.  Bigelow  is  of 
great  importance,  and  even  more  applicable  to  the  female  bladder  when 
no  cystitis  or  thickening  exists. 

In  1879,  Dr.  Edward  W.  Jenks  of  Detroit  published,  in  the  Amer- 
ican Journal  of  Obstetrics,  a  paper  upon  perineorrhaphy,  in  which  he 
described  a  method  devised  by  himself  for  denuding  the  mucous  sur- 
faces with  but  little  loss  of  blood.  His  method,  given  in  his  own 
words,  is  as  follows : 

"  The  patient  being  etherized,  I  begin  by  cutting  with  a  scissors  the 
anterior  margin  of  surface  to  be  denuded  at  the  juncture  of  integument 
and  mucous  membrane.  Next  I  introduce  two  fingers  of  the  left  hand 
into  the  rectum,  while  assistants  hold  the  labia  apart,  it  being  important 
that  they  are  held  uniformly  tense.  I  use  scissors  slightly  curved  and 
sharp-pointed  to  denude  the  mucous  membrane.  I  use  neither  tenacu- 
lum nor  tissue-forceps,  but  with  the  parts  tense  snip  a  hole  in  the 
mucous  membrane  in  the  median  line  close  to  the  integument,  and 
then,  inserting  the  scissors  with  a  cutting  motion  into  the  small  hole 
made,  I  continue  to  dissect  the  mucous  membrane  away  from  adjacent 
tissues  without  removing  the  scissors,  first  going  up  the  septum  as  far 
as  desired,  and  then  laterally,  first  on  one  side  and  then  on  the  other, 
without  removing  the  scissors  or  once  bringing  their  points  out  from 
beneath  the  mucous  membrane.  Then  with  blunt-pointed  scissors  I 
cut  away  the  dissected  flaps.  The  advantages  of  this  method  are — a, 
the  rapidity  with  which  it  can  be  done ;  h,  the  absence  of  hemorrhage 
in  the  vagina,  as  no  blood  escapes  at  the  locality  where  the  scissors  enter 
beneath  the  mucous  membrane ;  c,  the  ability  with  which  the  operator 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  53 

can  make  cuinplcte  (Icmidaliuii,  its  tlie  disculoratiuii  hciicatli  the  luiu-ou.s 
nionibraiie  marks  tlie  route  the  scissors  have  taken.  This  mode  of 
operating  is  only  applieahle  where  tliere  is  redundancy  of  tlie  tissues, 
autl  not  where  there  lias  been  great  loss  of  substance,  as  in  cases  where 
the  septum  has  been  torn  to  any  great  extent." 

The  same  author  describes  also  in  the  same  paper  a  new  method  of 
securing  the  sutures  in  the  operation  of  kolpo-perineorrliai)hy. 

In  this  same  year  there  was  a  valuable  contribution  on  the  subject 
of  ovarian  diseases  made  by  Dr.  Munde,  entitled  "  Prolajisus  of  the 
Ovaries."  In  this  paper  he  gave  points  in  diagnosis  and  modes  of 
treatment.  INIention,  however,  had  been  made  of  this  subject  in  the 
Journal  of  the  Gynecological  Society  of  Boston  in  1872  by  Storer, 
Warner,  and  Blake.  In  this  publication,  covering  the  results  of  his 
observations,  ]SIunde  calls  attention  to  the  fact  that  uncongested  ovaries 
may  become  prolapsed,  and  in  turn  prolapsus  leads  to  congestion.  He 
calls  attention  to  points  now  well  known,  that  many  of  these  cases  were 
undetected,  and  directs  attention  to  the  physical  and  mental  derange- 
ments to  which  they  lead.  He  also  directs  attention  to  the  value  of 
the  genu-pectoral  position  and  Sims's  speculum  as  aids  in  their  replace- 
ment. In  the  discussion  which  followed  this  paper,  which  was  read 
before  the  American  Gynecological  Society,  Dr.  Barker  recommended 
suppositories  of  iodide  of  lead  if  painting  the  vaginal  roof  with  iodine 
produced  too  much  irritation.  Drs.  Bozeman  and  Munde  had  found 
iodoform  useful  in  these  cases  for  the  relief  of  the  hyperaesthesia.  Dr. 
Albert  H.  Smith  advised  examination  by  rectum  for  diagnostic  pur- 
poses, and  Dr.  Skene  alluded  to  the  pain  during  and  after  defecation  as 
a  diagnostic  symptom.  Dr.  Taliaferro  of  Atlanta,  Ga.,  was  the  first  to 
suggest  packing  the  vagina  with  cotton  tampons  to  support  prolapsed 
ovaries.  In  April,  1878,  Dr.  Taliaferro,  in  a  paper  read  before  the 
Medical  Association  of  Georgia,  advocated  pressure  by  the  tampon  as  a 
therapeutic  in  the  treatment  of  uterine  and  periuterine  diseases. 

In  1880  a  paper  was  written  by  Dr.  Chadwick  advocating  the  use 
of  hot  rectal  douches  in  the  treatment  of  pelvic  inflammations. 

At  the  meeting  of  the  American  Gynecological  Society  in  1880, 
C.  D.  Palmer  of  Cincinnati  read  a  full  and  instructive  paper  entitled 
"  Laparotomy  and  Laparo-hysterotomy,  their  Indication  and  Statistics 
for  Fibroid  Tumors  of  the  Uterus." 

In  this  year  also  a  paper  was  read  by  Dr.  A.  Reeves  Jackson  of 
Chicago,  at  a  meeting  of  the  American  Gynecological  Society,  on 
"  Uterine  Massage  "  as  a  means  of  treating  certain  forms  of  enlarge- 
ment of  the  womb,  which,  although  not  wholly  original  with  the  writer, 
gave  rise  to  some  considerable  discussion  in  home  and  foreign  medical 
journals. 

In  1881  an  interesting  paper  was  published  by  Dr.  Van  de  Warker 


54  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY, 

in  which  he  recommends  forcible  elongation  of  pelvic  adhesions  in  cases 
where  they  cause  pain  during  defecation  or  other  straining  eiforts. 

In  this  year  Dr.  Thomas  published  a  paper  Upon  "  Laparotomy  com- 
plicated by  Expansion  of  the  Bladder  over  the  Surface  of  Abdominal 
Tumors,  and  its  Attachment  to  them  or  to  the  Abdominal  Walls."  He 
made  a  collection  of  reports  and  cases,  and  offered  the  following  mode 
of  procedure :  "As  diagnosis  even  by  the  sound  is  difficult,  if  it  is  not 
impossible,  this  complication  is  not  perceived  until  the  abdominal 
incision  is  made  or  the  bladder  laid  open.  If  it  happens  to  be 
attached  to  the  abdominal  parietes,  the  bladder  should  be  separated 
by  digital  detachment.  If  adliesion  is  too  close,  then  incise  the  ante- 
rior wall  of  the  bladder ;  if  incision  has  not  already  been  made,  with 
two  fingers  in  the  bladder  as  a  guide  the  adhesions  can  be  cut.  Then 
clamp  the  edges  of  incision  between  the  lips  of  the  abdominal  wound, 
and  close  by  silver  sutures." 

An  interesting  paper  by  Dr.  William  Goodell  of  Philadelphia  was 
published  on  "  Bursting  Cysts  of  the  Abdomen,"  in  which  the  author 
alludes  to  the  great  difference,  as  far  as  danger  is  concerned,  between 
parovarian  and  ovarian  cysts,  the  contents  of  the  former  usually  being 
limpid  and  innocuous,  and  the  fluid  eliminated  frequently  by  the  kid- 
neys, intestines,  or  skin,  and  is  usually  rapidly  taken  out.  In  case  of 
the  bursting  of  ovarian  cysts  the  danger  is  much  greater.  He  alludes 
to  a  case  seen  by  Dr.  Sims  in  1856  which  burst  three  times,  the  fluid 
being  eliminated  by  each  of  the  three  channels  mentioned — one  entirely 
by  the  kidneys,  another  entirely  by  the  intestines,  and  the  remaining 
one  wholly  by  the  skin. 

In  1882,  Dr.  Emmet  brought  to  the  notice  of  the  profession  his  new 
method  of  exploration  and  treatment  of  the  urethra  by  the  "  button- 
hole incision,"  as  he  designates  it.  He  first  essayed  this  method  in 
1879.  It  consists  of  a  buttonhole  incision  in  the  urethra  extending 
from  near  the  meatus  to  a  short  distance  from  the  neck  of  the  bladder, 
the  greatest  length  being  on  the  vaginal  mucous  membrane.  Retention 
is  not  impaired,  and  diagnosis  and  treatment  are  greatly  facilitated.  The 
special  advantage  of  this  method  is  the  facility  which  it  offers  to  the 
diagnosis  and  treatment  of  polypi  or  other  growths  about  the  neck  of 
the  bladder.     After  the  cure  is  effected  the  opening  is  easily  closed. 

In  this  year  Dr.  J.  C  Warren  of  Boston  offered  a  new  method  of 
operation  for  laceration  of  the  perineum  involving  the  sphincter  and 
rectal  wall.  The  operation  consists  in  dissecting  a  butterfly  flap  from  the 
posterior  vaginal  wall  above  the  rent,  and  a  similar  flap  from  above  down- 
ward, leaving  plenty  of  attachment  around  the  entire  edge  of  the  rup- 
tured rectal  wall  and  sphincter.  The  flap  is  turned  downward,  cover- 
ing the  rectal  rent.  The  freshened  edges  of  the  sphincter  are  brought 
together  over  the  flap,  which  hangs  out  of  the  anus  like  a  small  hemor- 


HISTORICAL  SKETCH  OF  AMERICAN  GVy ECOLOGY.  55 

rlioid.  All  iV('sli('iu'<l  surfaces  arc  then  hnmj^ht  in  coaptation,  the  flap 
being;  laid  in  folds.  The  i)art  hanging-  troni  the  anus  if  not  too  long 
will  draw  up  as  cicatrization  takes  place. 

In  Januarv  of  this  year  Dr.  Christian  Fen<i;er  of  Chieajro  recorded 
the  first  successful  operation  of  kolpo-hysterectoniy  for  uterine  cancer, 
at  which  time  he  also  advocated  the  operation  as  a  justifiable  one.  Dr. 
().  Stroinskv  of  C'hicairo  in  this  year  reported  a  novel  operati<tn  for 
traumatic  rupture  of  the  bladder :  while  removing  a  fibroid  jxtlypus 
from  the  bladder  by  twisting  he  made  a  rent  into  the  anterior  wall, 
inverted  the  whole  bladder  through  the  dilated  urethra,  repaired  the 
rent  by  three  sutures,  and  replaced  the  bladder.  The  result  wa.s 
recovery. 

In  1883,  Dr.  C.  C.  Lee  read  before  the  American  Gynecological 
Society  a  paper  on  the  injiu-ies  of  the  gravid  uterus  as  a  complication 
of  laparotomv.  From  a  study  of  a  necessarily  small  collection  of  cases 
both  at  home  and  abroad,  the  first  occurring  in  1856,  Dr.  Lee  con- 
cludes that — 1st,  the  gravid  uterus  may  be  wounded  without  neces- 
sarily producing  abortion ;  2d,  abortion  seems  to  depend  upon  opening 
the  ovisac ;  3d,  if  the  uterine  contents  are  injured  Csesarean  section  is 
indicated,  after  which  drainage  may  be  maintained  through  the  dilated 
cervix  ;  4th,  if  the  uterine  contents  are  uninjured,  the  wound  is  to  be 
treated  on  general  principles — namely,*  exact  coaptation  by  carbolized 
sutures. 

In  this  year,  too,  Emmet  describes  a  new  operation  for  so-called 
laceration  of  the  perineum.  It  is  considered  particularly  useful  where 
there  are  large  rectoceles.  In  this  paper  he  holds  that  the  loss  of  sup- 
port following  the  laceration  produced  by  childbirth  is  not  due  to  the 
injury  of  the  perineal  body.  In  fact,  he  denies  the  existence  of  any 
such  body,  and  claims  that  the  injury  is  due  rather  to  the  detachment 
of  perineal  muscles  and  the  perineal  fascia.  The  description  of  this 
operation  by  the  author  is  by  no  means  lucid,  but  it  substantially  con- 
sists in  a  semilunar  form  of  denudation,  wholly  within  the  vagina, 
of  such  extent  that  when  the  edges  are  brought  together  by  means 
of  sutures  the  "  slack "  in  the  posterior  M-all  is  entirely  taken  up  or 
made  to  disappear,  and  yet  the  ostium  vaginae  is  in  no  way  denuded  or 
directly  interfered  M'ith.  The  advantages  claimed  are — great  diminu- 
tion in  the  discomfort  following  immediately  after  the  oj^eration,  and 
the  perfect  juxtaposition  of  the  anterior  and  posterior  vaginal  walls,  as 
in  the  non-parous  woman. 

In  the  Transactions  of  the  American  Gynecological  Society  for  1883 
appears  a  paper  by  Dr.  E.  W.  Jenks  describing  a  new  mode  for  operat- 
ing for  fistula  in  ano.  In  the  same  volume  is  a  paper  of  Dr.  Emmet's, 
in  which  he  alludes  to  having  performed  the  operation  in  the  same 
manner,  neither  <rentleman  havino-  been  aware  of  the  fact  that  the  other 


56  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

had  performed  the  operation.  Dr.  Jenks's  first  operation  was  on  March 
31,  1881.  The  operation  consists  in  incising  the  fistulous  tracts  after 
the  usual  method,  dissecting  out  the  so-called  pyogenic  membrane  and 
all  lardaceous  and  cartilaginous  substances  along  the  route  of  the  fistula, 
and  also  cutting  away  all  portions  of  thin  livid  skin  of  low  vitality.  The 
incised  parts  are  maintained  in  perfect  apposition  by  means  of  deep  and 
superficial  sutures  until  adhesion  is  effected. 

In  this  year  Dr.  W.  H.  Byford  published  an  interesting  paper  upon 
chronic  abscesses  of  the  pelvis,  and  the  following  jDoints  are  made 
prominent :  When  the  surface  of  a  pelvic  abscess  is  identical  with  that 
of  an  external  ulcer,  granulations  may  be  exuberant  or  freely  movable 
and  flabby  or  firm  and  vigorous.  When  the  granulations  are  exuberant, 
forming  large  projections  into  the  abscess-cavity,  its  surfaces  should  be 
curetted.  The  same  operation  is  also  indicated  when  early  suppuration 
takes  place  in  pelvic  hsematoceles,  in  order  to  remove  the  clots  which 
suppuration  cannot  dispose  of.  As  granulations  disappear  and  cicatri- 
zation takes  place  the  contents  of  the  abscess  undergo  changes.  Serum 
exudes,  macerating  and  finally  disintegrating  the  pus-corpuscles  and 
causing  them  to  disappear.  Osmosis  going  on  through  the  cicatricial 
membrane  converts  the  contents  into  simple  serum.  There  then  results 
an  encysted  tumor  containing  serum-like  fluid. 

It  is  believed  that  Dr.  Charles  K.  Briddon  was  the  first  in  the  United 
States  to  perform  laparotomy  after  rupture  of  the  foetal  sac  in  tubal 
pregnancy.     This  he  did  in  October,  1883. 

Dr.  Matthew  D.  Mann  was  the  first  to  publish  a  successful  operation, 
performed  in  February,  1883,  in  which  he  removed  a  small  subperitoneal 
fibroid  tumor  of  the  uterus  through  the  anterior  wall  of  the  vagina. 

In  this  year  an  operation  for  the  cure  of  retroversion  of  the  uterus 
was  described  by  J.  B.  Hunter  of  New  York.  Dr.  O.  E.  Herrick  of 
Michigan  had  also  performed  and  reported  the  same  operation,  each 
gentleman  working  independently.  The  latter,  however,  it  is  believed, 
is  entitled  to  the  credit  of  being  the  first  to  perform  the  operation. 
The  operation  consists  of  a  denuded  surface  upon  the  posterior  lap  of 
the  uterus  which  is  united  by  sutures  to  a  similarly  denuded  surface 
upon  the  posterior  vaginal  wall. 

In  the  January  number  of  the  American  Journal  of  Obstetrics  of  this 
year  Dr.  Garrigues  of  New  York  published  a  paper  upon  laparo- 
elytrotomy.  In  this  paper  he  alluded  to  the  place  of  incision  and  the 
position  of  the  ureters,  and  pointed  out  how  they  might  be  avoided 
during  operations.  Dr.  Polk  of  New  York  had  written  upon  the  sub- 
ject the  previous  year,  and  Dr.  Garrigues  had  himself  investigated  it 
in  1878.  Drs.  Polk  and  Garrigues  agree,  from  experiments  made  upon 
the  cadaver,  that  in  the  operation  of  laparo-elytrotomy  the  ureter  is 
safer  from  injury  if  it  remains  below  rather  than  above  the  incision. 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  .07 

In  November  of"  this  year  Dr.  B.  Bernard  Brown  of  Baltimore  per- 
formed a  new  operation  for  the  rediietion  of  an  inverted  uterus.  An 
ineision  was  made  in  the  fundus  of  the  uterus,  tlirough  whieh  he  passed 
one  of  Sims's  hirge  dilators  up  through  the  cervix,  expanding  the  lat- 
ter to  the  fullest  extent.  He  then  passed  through  hard-rubber  dila- 
tors, and  having  assured  himself,  by  means  of  the  linger,  that  no 
adhesions  existed,  the  incision  of  the  fundus  was  sutured,  and  with 
some  manipulation  the  fundus  was  easily  pushed  up  through  the  now 
dilated  cervix,  and  the  operation  was  complete. 

In  1884  a  valuable  paper  was  published  by  Dr.  Palmer  of  Cincin- 
nati, entitled  "Abdominal  Section,  its  Value  and  Range  of  Application 
a.s  a  Means  of  Exploration  and  Treatment."  This  paper  was  read 
before  the  American  Gynecological  Society,  and  gave  rise  to  much 
valuable  discussion.  In  this  year  an  instructive  paper  by  Dr.  Thomas 
appeared,  entitled  "  Management  of  the  Placenta  after  Laparotomy  in 
Abdominal  Pregnancy  at  Full  Term  or  Beyond." 

An  unique  and  interesting  article  from  Dr.  Isaac  E.  Taylor  of  Xcav 
York  M'as  published  upon  physiognomy  of  the  vulva  following  anal 
diseases.  Dr.  Taylor  had  made  observations  in  this  connection  which 
may  be  considered  as  very  useful  in  diagnosis.  He  directs  attention  to 
anal  diseases  causing  changes  in  the  appearance  of  the  vulva  as  painful 
affections,  coming  under  the  head  of — 1st,  spasmodic  contractioiLS  of 
the  anus ;  2d,  neuralgia  or  hysterical  hj-peraesthesia ;  3d,  irritability  or 
indolent  fissure  in  that  localit}^ 

An  interesting  article  was  published  in  the  American  Journal  of 
Obstetrics  of  November,  1883,  to  March,  1884,  by  Dr.  H.  R.  Bigelow, 
entitled  "  Gastrotomy  for  Myo-fibromata  of  the  Uterus."  It  is  one  of 
the  most  valuable  contributions  to  om-  knowledge  of  the  subject  up  to 
that  time.  He  alludes  to  the  publication  in  1853,  by  AY.  L.  Atlee,  of 
a  paper  entitled  "  Surgical  Treatment  of  Certain  Fil^rous  Tumors  of 
the  Uterus  "  as  the  beginning  of  a  movement  in  the  treatment  of  ute- 
rine fibroids.  Until  1863  a  few  surgeons  at  home  and  abroad,  like 
Atlee,  Burnham,  and  Kimball,  on  opening  the  abdomen  for  ovarian 
tumors,  having  found  a  uterine  tiunor,  ventured  to  remove  it.  Burnham 
made  a  supravaginal  hysterectomy  June  26, 1853,  and  the  patient  recov- 
ered. This  was  the  first  successful  case  in  America.  Afterward  Koeberle 
of  Strasburg  was  the  first  to  deliberately  open  the  abdomen  for  the  purpose 
of  removing  uterine  fibroids  and  fibrous  cysts,  which  he  did  by  ligature 
if  pedunculated,  or  by  the  performance  of  hysterectomy  if  they  were 
intramural  or  sessile.  Dr.  Storer  was  among  the  first  in  America  to 
deliberately  follow  in  his  footsteps.  Dr.  Kimball  of  Lowell  with  equal 
boldness  operated  about  the  same  time  as  Koeberle. 

In  writing  of  early  operators  Bigelow  states  that  "Kimball  and 
Koeberle  seem  to  be  the  only  ones  whose  operations  were  based  upon  a 


58  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

correct  diagnosis."  The  present  status  of  such  a  treatment  of  myo- 
fibromata  of  the  uterus  was  concisely  set  forth  in  this  year  by  Dr. 
R.  S.  Sutton  of  Pittsburg  in  an  article  on  "Non-malignant  Tumors 
of  the  Uterus ;"  and  several  American  writers  on  uterine  fibroids  give 
Dr.  Goodell  the  credit  of  being  the  first  in  the  United  States  to  remove 
ovaries  to  prevent  further  growth  in  uterine  fibroids,  but  the  date  of  his 
operation  we  are  unable  to  state. 

Dr.  H.  A.  Kelly  of  Philadelphia  reports  a  successfiil  operation  for 
sessile  cervical  fibroids  above  the  vaginal  roof  by  abdominal  incision. 
Free  hemorrhage  was  checked  by  the  use  of  Paquelin's  cautery  apj)lied 
deep  in  the  j)eritoneal  cavity.  The  first  successfiil  case  of  laparotomy 
for  pelvic  abscess  in  this  country  was  made  by  Dr.  R.  S.  Sutton  in 
June,  1884. 

A  very  interesting  address  was  made  at  the  meeting  of  the  American 
Gynecological  Society  in  1885  by  Dr.  Wm.  T.  Howard  upon  encysted 
tubercular  peritonitis.  He  had  collected  from  various  sources  six  cases 
in  which  there  was  interference  :  one  of  these  was  aspirated,  three  tap- 
ped, two  operated  upon  as  in  ovariotomy,  and  all  died.  One  case  was 
simply  treated  by  hygienic  and  therapeutic  measures,  and  recovered. 
Some  of  his  clinical  conclusions  are  that  tubercular  peritonitis  appears 
in  early  life.  Its  development  is  rapid,  varying  from  six  weeks  to 
eight  months.  Being  rarely  a  local  affection,  we  should  search  for 
indications  of  the  disease  in  other  parts  of  the  body.  A  number  have 
observed  that  a  red  blush  of  the  central  anterior  part  of  the  abdom- 
inal wall  is  characteristic  of  tubercular  peritonitis. 

At  the  meeting  of  the  Gynecological  Society  of  this  year  (1885)  quite 
a  lengthy  discussion  was  held  upon  modifications  of  Emmet's  operation 
upon  the  cervix  uteri,  called  forth  by  a  paper  of  Dr.  Sutton's.  The 
majority  of  the  members  participated  in  this  discussion,  and  the  fact 
was  clearly  demonstrated  that  the  mechanical  ingenuity  of  the  different 
gynecologists  is  of  the  highest  order. 

Dr.  Goodell  reported  this  year  having  observed  a  form  of  parotitis 
following  operations  upon  the  female  genital  organs  which  was  not  of 
septic  origin.  That  such  diseases  might  occur  is  owing  to  the  relation- 
ship which  is  known  to  exist  between  the  sexual  organs  of  the  adult 
and  the  cervical  and  salivary  glands.  The  inflammation  observed  by 
Goodell  closely  resembles  mumps,  and  usually  ends  in  resolution  unat- 
tended with  any  of  the  signs  of  septicaemia,  such  as  frequency  of  the 
pulse  or  glassy  apearance  of  the  eye.  This  variety  of  parotitis  lasts 
longer  than  mumps.  Instead  of  the  patient  failing  as  in  septic  inflam- 
mation, she  gains  pari  passu  with  the  continued  enlargement  of  the 
glands.  His  first  case  was  reported  to  the  Obstetrical  Society  of  Phil- 
adelphia in  October,  1884. 

In  this  same  year  Dr.  Alfred  C.  Post  of  New  York  reported  a  new 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  59 

form  ol' operation  lor  lacerated  ju'riiieuiii,  wliidi  may  be  briefly  described 
as  follows  :  An  ineisjon  ol"  liallaii  inch  in  de|)tli  is  made  upon  each  side 
of  the  vagina  in  sneh  a  manner  as  to  make  upper  and  lower  segments. 
The  upper  segments  are  turned  up  to  form  the  floor  of  the  vagina  and 
secured  by  a  row  of  catgut  sutures  passed  through  the  subcutaneous  tis- 
sues. A  row  of  silver  sutures  is  passed  beneath  the  bottom  of  the 
incision.     The  lower  edges  are  also  united  by  fine  sutures. 

In  the  New  York  Medical  Jomiial  of  this  year  Dr.  John  Scott  of 
San  Francisco  reports  a  case  of  chronic  pelvic  abscess  treated  by 
abdominal  incision.  After  the  abscess-cavity  was  Avashed  out  a  drain- 
age-tube Avas  passed  through  the  incision  into  Douglas's  cul-de-sac  and 
through  into  the  vagina.  The  abdominal  incision  was  then  closed ; 
recovery. 

In  June  of  this  year  Dr.  B.  E.  Hadra  of  San  Antonio,  Texas,  read 
a  paper  before  the  section  of  Diseases  of  Women  at  the  American 
Medical  Association,  entitled  "  Intraperitoneal  Adhesions  in  Relation 
to  Tait's  Operation."  He  calls  attention  to  the  marked  relief  in  some 
cases  after  Tait's  operation  in  which  disease  of  the  tubes  and  ovaries 
was  not  extensive.  This  fact  he  considers  due  rather  to  the  breaking 
up  of  adhesions — namely,  of  the  intestines  to  the  fundus  or  sides  of  the 
uterus ;  also  extra-pelvic  adhesions,  especially  adhesions  between  the 
omentum  and  parietal  or  visceral  peritoneum.  He  advocates  laparot- 
omy for  a  new  purpose — namely,  to  free  the  peritoneum  throughout  its 
entire  area. 

In  a  paper  on  vulvar  and  vaginal  enterocele,  read  before  the  New 
York  Academy  of  Medicine  in  1885,  Dr.  T.  G.  Thomas  advocated  a 
ne^v  method  of  treatment  for  vaginal  enterocele  in  cases  not  amenable 
to  the  ordinary  measures — namely,  laparotomy  and  dragging  up  the 
hernial  sac  and  fastening  it  to  the  abdominal  wound.  He  reports  one 
case  in  which  this  plan  was  partially  pursued  with  successful  result. 

In  a  series  of  articles  in  the  American  Journal  of  Obstetrics  in  1885, 
entitled  "  Studies  in  Endometritis,"  Dr.  Mary  Putnam-Jacobi  further 
develops  the  cyclical  theory  of  menstruation  which  was  first  enunciated 
in  1878  by  Dr.  Goodman  of  Louisville.  The  theory  which  she  sets 
forth  is  substantially  as  follows  :  The  endometrium  above  the  os  inter- 
num, the  mucosa  of  the  Fallopian  tubes,  and  the  cortex  of  the  ovaries 
are  designated  a^  the  " gerrninative  membrane.^'  "The  epithelium  and 
subepithelial  cells  of  this  membrane  are  directly  derived  from  the  ger- 
minal epithelium  of  the  embr^^onic  hypoblast  which  covers  the  repro- 
ductive eminences  of  the  pleuro-peritoneal  cavity."  .  ..."  In  all  the 
elements  of  germinative  membranes  persists  the  embryonic  property 
of  indefinite  groMi:h."  This  process  is  changed  from  continuous  to 
cyclical  through  the  mechanical  obstructions  which  are  encountered 
after  a  certain  point  in  groAvth  is  reached.     Dr.  Jacobi,  like  Dr.  Good- 


60  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

man,  separates  ovulation  and  menstruation  as  far  as  cause  and  effect  are 
concerned.  Ovulation  and  menstruation  are  usually  synchronous.  The 
former  does  not  cause  the  latter,  but  both  are  produced  by  the  same 
cause — namely,  growth  of  embryonic  tissue. 

In  1885,  Dr.  Baird  of  Texas  advocated  a  new  method  for  the  treat- 
ment of  pelvic  cellulitis  for  arresting  exudation  and  pain,  and  applies 
the  galvanic  current.  He  reports  a  case  also  where  pus  had  formed, 
which  he  evacuated  by  asjDiration,  and  then  injected  the  cavity  with 
salt  water,  and  applied  a  galvanic  current  to  the  cavity,  with  the  result 
of  speedy  contraction  of  the  abscess  and  radical  cure. 

In  1886,  Dr.  Sarah  E.  Post  published  in  the  Ameriean  Journal  of 
the  Medical  Sciences  an  exhaustive  resum^  upon  the  subject  of  kolpo- 
hysterectomy,  which  comprises  a  collection  of  all  cases  on  record,  with 
a  short  history  and  description  of  each  of  the  various  modes  of  ope- 
rating. 

Dr.  H.  Marion  Sims  of  New  York  read  this  same  year,  before 
the  New  York  Obstetrical  Society,  a  paper  on  ventral  hernia  following 
ovariotomy,  in  which  he  advocates  a  radical  operation  for  its  cure.  In 
a  patient  who  suffered  very  much  pain  on  account  of  the  hernia,  the 
hernial  ring  being  ten  inches  in  diameter,  he  excised  an  elliptical  piece 
of  skin,  and  then  united  the  peritoneum  by  Lembert  sutures.  Then 
the  muscles  and  fascia  were  united  separately  with  catgut  and  silver 
wire.     The  result  was  a  perfect  recovery. 

Dr.  Polk  of  New  York  reported  to  the  Obstetrical  Society  of  New 
York  a  case  of  pelvic  abscess  which  was  operated  upon  outside  of  the 
peritoneum  by  means  of  an  incision  made  as  in  that  for  ligating  the 
iliac  artery,  the  patient  recovering. 

January  20th  of  this  year  the  first  annual  meeting  of  the  Alumni  As- 
sociation of  the  Woman's  Hospital  of  the  State  of  New  York,  composed 
of  former  medical  officers  and  house-surgeons,  was  held.  A  permanent 
organization  was  effected,  and  Dr.  J.  B.  Hunter  was  chosen  president. 
At  this  meeting  many  interesting  papers  were  read  and  discussed,  most 
of  which  have  been  published  in  medical  journals ;  a  history  of  the 
institution  was  also  read,  it  being  altogether  a  meeting  of  the  alumni. 

In  mentioning  the  historical  points  heretofore  the  writer  has  aimed 
to  pursue  a  chronological  order,  but  there  are  some  items  relating  to 
gynecological  history  which,  being  matters  of  development,  can  hardly 
be  spoken  of  as  pertaining  wholly  to  any  one  year,  and  therefore  will 
now  be  alluded  to. 

In  this  connection  attention  is  directed  to  the  use  of  electricity  in 
the  treatment  of  uterine  fibroids.  Among  those  who  have  investigated 
this  subject  and  experimented  and  published  their  results  may  be  men- 
tioned Dr.  J.  N.  Freeman  of  Brooklyn,  Dr.  Engelmann  of  St.  Louis, 
Dr.  Everett  of  Clyde,  O.,  Dr.  Martin  of  Chicago.     These  gentlemen 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  01 

have  writtru  upon  I'k'ctrolysi.s  in  the  treatment  of"  .sub])eritoneal  ;ui(l 
intramural  fibroids.  Drs.  Thomas,  Muntl6,  Vanderveer,  and  Semelloder 
of  Mexico  have  exj)erimented  and  written  n])on  electrolysis  in  the  treat- 
ment of  ovarian  tumors.  Dr.  INIiuide  ^ives  a  report  of  fifty-one  cases 
which  he  has  collected  from  various  sources,  of  which  there  were  nine 
deaths  and  fourteen  failures,  the  remainder  beinjr  benefited  or  cured. 

In  1874,  Dr.  Gihuan  Kimball  published  in  the  Boston  Medical 
Journal  a  paper  entitled  "  Treatment  of  Uterine  Fibroids  by  Electrol- 
ysis or  Galvanism."  In  1878,  Ej)hraim  Cutter  reported  fifty  cases  of 
uterine  fibn)ids  treated  by  electrolysis  by  Kimball  and  himself.  These 
cases  were  treated  during  the  period  extending  from  1871  to  1877,  with 
the  following  results  :  Non-arrests,  7  ;  death,  4 ;  arrests,  32  ;  relieved, 
3;  cured,  4.  Writing  of  these  cases  nine  years  later  (in  1887),  Cutter 
shows  that  time  has  served  to  strengthen  rather  than  weaken  the  posi- 
tion which  he  and  Kimball  took  as  pioneers  of  this  method,  for  the 
present  resume  of  those  same  fifty  cases  now  stands  thus  :  Non-arrests, 
7;  fatal,  4;  arrests,  25;  relieved,  3;  cured,  11. 

Dr.  Robert  Ne\vman  of  New  York  is  the  veteran  advocate  in  America 
of  the  electrolytic  treatment.  He  reported  the  results  of  some  of  his 
labors  in  this  direction  as  early  as  1867.  Reports  of  successful  cases 
of  electrolysis  in  extra-uterine  pregnancy  have  been  made  by  Drs.  A. 
D.  RockAvell,  T.  G.  Thomas,  E.  G.  Landis,  N.  Bozeman,  Garrigues,  J. 
C  Reeve,  William  T.  Lusk,  and  others. 

Hot  water,  which  is  so  generally  made  use  of  in  the  treatment  of 
diseases  peculiar  to  women,  and  has  had  such  an  ardent  advocate  in 
Dr.  Emmet,  w^os  first  brought  to  the  attention  of  the  profession  as  a 
hnemostatic  during  surgical  operations  by  the  late  Dr.  Pitcher  of  Detroit 
in  1859. 

A  valuable  contribution  to  gynecology  has  been  made  by  Dr.  H. 
Coe,  the  pathologist  of  the  Woman's  Hospital  of  New  York.  His 
published  observations  of  certain  conditions  of  the  ovaries  have  been 
revelations  to  many  who  believed  that  an}i;hing  appearing  like  a  cyst 
upon  the  ovary  indicates  disease  demanding  removal.  Some  of  his 
conclusions  are  as  follows :  Laparotomists  often  judge  of  ovarian  dis- 
eases by — 1st,  thickening  of  the  cortex  of  ovaries  :  such  thickening  is 
perfectly  normal  in  the  senile  organ  or  after  frequent  ovulation;  2d,  by 
the  appearance  of  a  "  cystic  "  degeneration,  which  is  often  only  hydrops 
folliculorum,  and,  according  to  Olshausen,  "the  stroma  of  the  ovary 
in  these  cases  is  intact  and  most  of  the  vesicles  are  normal."  This  con- 
dition seldom  attains  any  clinical  importance,  because  the  changes  pro- 
duce no  symptoms.  Dr.  Coe  states  the  case  of  a  perfect  ovum  found 
within  a  Graafian  vesicle  as  large  as  a  marble.  Of  a  large  number  of 
tubes  removed  by  different  operatoj's  which  Coe  has  examined,  only  one- 
fifth  had  true  pyosalpinx.     A  less  number  were  affected  with  hydro- 


62  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

salpinx,  and  only  one  with  lisematosalpinx.  An  acute  catarrhal  sal- 
pingitis had  been  found  in  women  who  had  died  from  acute  peritonitis 
following  extension  of  acute  purulent  endometritis.  Chronic  catarrhal 
salpingitis  he  has  not  found.  Thickening  of  the  fibroid  muscular  tis- 
sue without  evidence  of  inflammation  is  rare.  This  condition  has  been 
designated  pachysalpingitis.  Coe  gives  this  as  a  rule :  Unless  pus  is 
found  there  is  no  pyosalpinx. 

In  1882,  Dr.  Baker  of  Boston  originated  the  cone-shaped  excision 
of  the  neck  of  the  uterus  for  cancer,  the  apex  of  the  cone  being  carried 
far  above  the  os  internum.     Dr.  Baker  has  also  cured  a  case  of  con- 
genital malposition  of  the  ureter.     The  ureter  opened  into  the  vagina 
near  the  meatus  urinarius.     He  dissected  up  a  portion  of  the  misjjlaced 
ureter,  made  an  opening  in  the  original  bed  near  the  neck  of  the  blad- 
der, and  turned  the  stump  through  it  and  closed  the  vaginal  wall  over 
it.     About  a  year  after  he  was  obliged  to  open  the  bladder  and  remove 
a  stone  which  had  probably  formed  as  the  result  of  leaving  a  raw  sur- 
face in  the  bladder.    Phosphates  are  often  deposited  upon  such  surfaces. 
In  1886,  at  a  meeting  of  the  American  Medical  Association,  Dr.  A. 
F.  Pattee  reported  great  success  for  many  years  with  potassium  chloride 
in  the  treatment  of  anaemia,  exudations  from  pelvic  cellulitis  in  ovarian 
neuralgia,  menstrual  headache  with  wakefulness,  he  having  found  the  rem- 
edy more  advantageous  than  potassium  bromide  or  ammonium  chloride. 
Dr.  Byrne  of  Brooklyn  in  the  October  and  December  numbers  of  the 
New  York  Medical  Journal  for  1878  published  a  new  method  of  redu- 
cino-  inversion  of  the  uterus  bv  means  of  an  instrument  consisting  of  a 
curved  stem,  to  the  end  of  which  is  attached  a  cup  for  receiving  the 
inverted  uterus.     The  stem  is  traversed  by  a  rod  which  is  affixed  to 
a  disk  forming  a  false  bottom  of  the  cup.     Counter-pressure  upon  the 
abdomen  is  maintained  by  means  of  an  open  bell-shaped  cup,  through 
the  centre  of  which  passes  a  screw  provided  at  the  lower  end  with  a 
conical  plug  of  hard  rubber,  and  on  the  opposite  or  lower  extremity  a 
flat  knob  for  a  handle. 

Heretofore,  in  speaking  of  the  mechanical  treatment  of  uterine  dis- 
placements, credit  has  been  given  to  Dr.  Hodge  for  his  ingenuity,  but 
American  ingenuity  has  been  taxed  to  its  utmost  in  the  invention  of 
pessaries,  the  most  valuable  of  which  are  some  form  or  modification  of 
the  one  originally  invented  by  Hodge.  Among  those  most  worthy  of 
mention  are  the  pessaries  of  Thomas,  Emmet,  and  Albert  H.  Smith. 
Gehrung  of  St.  Louis  has  devised  various  forms — one  particularly 
useful  in  anteversion  or  procidentia  accompanied  by  anteversion  or 
cystocele — and  so  has  Cutter.  All  forms  of  gynecological  instru- 
ments have  been  devised,  and  there  is  scarcely  an  operator  but  has 
originated  or  modified  some  form  of  instrument,  to  which  his  name 
is  attached. 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  63 

One  of  the  improved  pessaries  is  tlie  bloelv-tin  jK'ssarv  devised  by 
Sims  about  185!).  lie  reeoL>,iu/ed  tlie  neeessity  of"  liaving  a  pessary  fit 
the  eanal  in  which  it  was  to  be  phieed,  and  devised  pessaries  from  that 
material  to  aeeomplish  this  j)urpose. 

Prior  to  Dr.  Siius's  book  most  of  the  works  piiljlislied  in  this  coun- 
try upon  diseases  of  women  were  either  foreign  works  edited  by  Ameri- 
can physicians  or  were  treatises  chiefly  u[)on  diseases  of  the  puerperal 
state.  In  182(j  was  published  the  treatise  on  Diseases  of  Females,  by 
William  P.  Dew'ees.  This  book  reached  its  tenth  edition.  From  1852 
to  1855  the  clinical  lectures  of  Dr.  G.  S.  Bedford  were  publislied  in 
medical  journals,  after  which  they  were  published  in  book  form.  The 
work  of  Dr.  C.  D.  Meigs,  published  in  1850,  which  ran  through  several 
editions  and  was  written  in  the  most  charming  manner,  was  in  no  degree 
a  representative  of  modern  gynecology.  In  1860  was  published  Z)t.s-- 
eases  Peculiar  to  Women,  including  Displacements  of  the  Uterus,  by  Hugh 
L.  Hodge.  The  first  edition  of  Byford's  work  upon  medical  and  sur- 
gical treatment  of  women  was  in  1865.  Dr.  Marion  Sims's  book,  en- 
titled Clinical  Notes  on  Uterine  Surgery,  was  published  in  1866.  In 
1868  a  treatise  upon  vesico-vaginal  and  vesico-rectal  fistula,  by  T.  A. 
Emmet,  was  published.  In  1868  was  published  a  book  by  T.  Gail- 
lard  Thomas  entitled  Practical  Treatise  upon  the  Diseases  of  Women. 
This  work  was  the  fullest  and  most  systematic  treatise  that  had  ever 
emanated  from  an  American  author.  As  early  as  1880,  so  great  had 
been  the  demand  for  this  book,  it  had  run  through  four  editions,  and 
the  fifth  was  published,  much  revised  and  enlarged.  Especially  note- 
worthy are  the  chapters  entitled  respectively  "An  Historical  Sketch 
of  Gynecology "  and  "  The  Anatomy,  Physiology,  and  Pathology  of 
the  Female  Perineum."  The  former  is  a  concise  and  most  interesting 
article  on  gynecology,  dating  back  to  ancient  times.  The  latter,  an 
ably-written  chapter,  has  especial  reference  to  the  functions  of  the 
perineal  body  and  the  necessity  of  restoring  it  afber  rupture,  even 
though  incomplete. 

The  first  journal  devoted  to  obstetrics  and  gynecology  appeared  in 
1868,  edited  by  Dr.  B.  F.  Daw^son,  to  whose  energy  and  untiring  efforts 
chiefly  this  journal  owes  its  origin.  It  first  appeared  as  a  quarterly. 
After  some  years  Dr.  Dawson  was  succeeded  by  its  present  able  editor. 
Dr.  ]\Iunde.  The  first  journal  devoted  especially  to  gynecology  was 
the  Journal  of  the  Gynecological  Society  of  Boston,  edited  by  Drs.  H. 
R.  Storer,  G.  H.  Bixby,  and  W.  Lewis.  It  first  appeared  in  1869, 
and  exercised  no  inconsiderable  amount  of  influence. 

In  1872,  Dr.  E.  N.  Chapman,  a  former  professor  of  obstetrics 
and  diseases  of  women  in  the  Long  Island  College  Hospital,  pub- 
lished his  work  on  Diseases  and  Displacements  of  the  Uterus,  which 
met  with  rather   rough   usage  at  the  hands  of  reviewers,  although 


64  HISTORICAL  SKETCH  OF  AMERICAN   GYNECOLOGY. 

possessing  considerable  merit.  The  book  never  reached  its  second 
edition. 

In  1872^  Dr.  John  Byrne's  (of  Brooklyn)  monograph,  entitled  Clin- 
ical Notes  on  the  Elective  Cautery  in  Uterine  Swgery,  was  published. 
Notwithstanding  this  gentleman's  enthusiastic  advocacy  of  the  electric 
cautery  and  the  good  showing  of  his  clinical  reports,  this  mode  of 
treatment  is  not  at  the  present  time  held  in  the  high  esteem  it  once 
was  by  leading  American  gynecologists. 

In  1872  was  published  by  Appletons  the  truly  classical  Avork  On 
Ovarian  Tumo'^s,  by  Edmund  R.  Peaslee,  which  was  dedicated  "  To 
the  memory  of  Ephraim  McDowell,  M.  D.,  the  father  of  ovariotomy, 
and  to  Thomas  Spencer  Wells,  Esq.,  the  greatest  of  ovariotomists." 
Of  this  great  work  his  friend  and  biographer.  Professor  Fordyce 
Barker,  writes  for  the  third  volume  of  the  Transactions  of  the  Amer- 
ican Gynecological  Society:  "No  work  has  been  published  in  this  coun- 
try on  any  special  subject  of  medical  science  of  higher  merit  than  his, 
as  regards  its  plan  of  arrangement,  its  artistic  excellence  of  execution, 
its  literary  finish,  its  learned,  impartial,  historical  research,  its  sound- 
ness in  pathology,  its  keen  analytical  teaching  of  diagnosis,  its  wise, 
prudent,  practical,  and  thorough  directions  as  regards  treatment,  both 
in  the  medical  and  surgical  aspects  of  the  subject."  This  M'ork  will  be 
"  an  imperishable  monument  to  his  name." 

Soon  after  Peaslee's  book  was  published  appeared  another  work  (in 
1873)  on  Ovarian  Tumors,  which  had  been  announced,  and  the  publi- 
cation of  which  had  been  eagerly  anticipated  by  all  interested  in  the 
operation  of  ovariotomy  in  the  United  States.  The  work  referred  to 
was  written  by  Washington  L.  Atlee,  who  up  to  this  date  had  made 
more  ovariotomies  than  any  other  American.  This  truly  valuable  book 
differs  widely  from  Peaslee's,  as  it  is  more  purely  clinical  and  personal, 
showing  as  it  does  the  many  years  of  its  author's  labors  as  a  pioneer 
ovariotomist.  The  twenty-fourth  chapter  of  this  volume,  entitled 
"  Dropsical  Fluids  of  the  Abdomen,  their  Physical  Properties,  Chem- 
ical Analysis,  Microscopic  Appearance,  and  Diagnostic  Value,  based  on 
the  Examination  of  Several  Hundred  Specimens,"  was  contributed  by 
Dr.  Thomas  M.  Drysdale. 

In  1876  appeared  the  first  volume  of  the  Transactions  of  the  Ameri- 
can Gynecological  Society,  which  have  appeared  from  year  to  year  since 
that  time.  Allusion  has  herein  before  been  made  to  the  organization 
of  this  society  and  the  influence  which  it  has  exerted  on  the  progress 
of  gynecology  in  this  country.  Nor  has  this  influence  been  confined  to 
the  United  States  alone,  but  has  been  felt  in  foreign  countries.  After 
the  appearance  of  the  sixth  volume  of  the  Transactions  the  following 
introduction  to  a  translation  of  one  of  its  articles  by  the  distinguished 
Prof.  Kleinwachter  appeared  in  the  Deutsches  Archiv  fiir  Geschichte  der 


HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY.  65 

Med.  ic  Jli'd.  (icog.,  in  which  the  translation  was  published.  Ai'tor 
writing-  at  sumo  length  in  a  eonuncndatorv  maimer  of  the  foundation 
of  the  society  and  its  founders  and  Tntn.sdclioiis,  lie  says:  "  Uj)  to  the 
present  time  six  vohimcs  have  appeared,  \\  hich  are  an  ornament  to  our 
libraries  of  special  sciences  and  contain  an  abundance  of  highly  inter- 
esting and  valuable  contributions,  a.s  would  be  expected,  Ibr  amongst 
the  co-workers  may  be  enumerated  such  men  as  Washington  Atlee, 
Fordyce  Barker,  William  Byford,  Thomas  Addis  Emmet,  George  En- 
gelmann,  William  Goodell,  Charles  Carroll  Lee,  William  Lusk,  Paul 
Mund6,  Emil  Noeggerath,  Randolph  Peaslee,  the  universally-kno\vn 
and  celebrated  Dr.  J.  INIarion  Sims,  T.  Gaillard  Thomas,  and  others 
whose  scientific  reputation  is  everywhere  known  and  recognized." 
Aside  from  the  scientific  interest  which  the  Transactions  possess, 
Kleinwiichter  considers  the  medico-historical  characteristics  note- 
worthy :  "  The  previous  volumes  contain  full  biographies  of  Simon 
(of  Heidelberg),  Charles  Buckingham,  Randolph  Peaslee,  Marmaduke 
B.  Wright,  and  others.  The  fifth  volume  contains  an  extensive  paper, 
illustrated  with  numerous  cuts,  upon  midwifery  among  the  various 
peoples  of  the  globe,  by  Engelmann,  and  in  the  sixth  is  a  noticeable 
contribution  from  the  pen  of  Edward  W.  Jenks  entitled  '  The  Prac- 
tice of  Gynecology  in  Ancient  Times.' "...."  If  the  English  and 
French  cultivate  the  history  of  medicine,  we  need  be  less  surprised,  for 
both  of  these  nations  possess  a  famous  history  of  more  than  a  thousand 
years,  and  such  a  one  doubtless  stimulates  historical  research.  The 
Americans  are  without  an  ancient  national  culture,  and  therefore  with- 
out an  ancient  history,  and  yet  we  see  them  fostering  the  history  of 
medicine.  With  this  people  xo.t  £^oyrjV  of  the  present,  necessity  has 
compelled  it  to  make  a  path  for  itself,  in  order  to  learn  what  the 
ancients  knew  and  did,  in  order  not  to  be  too  one-sided — in  other 
words,  more  fully  to  comprehend  the  spirit  of  medicine  than  it  is 
possible  by  the  modern  methods  of  so-called  exact  investigation." 

In  1878  was  established  the  Obstetric  Gazette,  published  in  Cincin- 
nati and  edited  by  Edward  B.  Stevens ;  it  has  also  a  department 
devoted  to  diseases  of  women. 

Dr.  Skene's  book,  entitled  Diseases  of  the  Bladder  and  ZTrethra  of 
Women,  first  came  out  in  1878.  This  volume  is  the  only  one  of  its 
kind  which  has  been  published  in  this  country,  and  its  intrinsic  value 
has  greatly  served  to  establish  and  extend  the  justly-deserved  reputa- 
tion of  its  author  as  an  authority  on  the  disorders  of  ^\hich  it  treats. 

In  1879,  Emmet  published  his  work  entitled  Principles  and  Practice 
of  Gyna'colngii.  This  work  is  a  clinical  work,  and  is  tqtally  unlike  the 
systematic  treatise  of  Thomas.  Owing  to  the  author's  long  connection 
with  the  Woman's  Hospital  of  the  State  of  New  York,  first  as  assistant 
to  Dr.  Sims,  next  as  surgeon-in-chief  for  many  years,  and  later  as  one 
Vol.  I.— 5 


66  HISTORICAL  SKETCH  OF  AMERICAN  GYNECOLOGY. 

of  the  surgeons  of  the  staif,  his  experience  has  given  him  great  advan- 
tages in  the  way  of  clinical  observation,  of  which  his  book  bears  an 
abundant  evidence.  This  book  has  passed  through  several  editions, 
the  last  one  being  practically  a  new  book,  so  much  has  been  rewritten 
and  added  since  the  first  edition  appeared. 

In  1879  was  published  the  clinical  lectures  of  Dr.  Wm.  Goodell  of 
Philadelphia,  entitled  Lessons  in  Gynaecology. 

In  1881  a  new  edition  of  By  ford's  work  was  published  on  the  dis- 
eases of  women,  but  so  changed  from  the  first  edition  as  to  be  practi- 
cally a  new  work,  fully  abreast  of  the  times  and  worthy  of  its  indus- 
trious author. 

In  1880,  Mund6  published  a  work  entitled  Minor  Surgical  Gyne- 
cology, The  second  edition  appeared  in  1885 — a  work  of  great  use 
to  the  younger  members  of  the  profession,  for  whom  chiefly  it  is 
written. 

Obstetrical  societies  were  formed  many  years  ago  in  a  few  of  the  larger 
cities,  but  the  first  gynecological  society  organized  was  the  Gynecolog- 
ical Society  of  Boston,  established  in  1869.  Its  Transactions,  pub- 
lished monthly,  exerted  a  widespread  influence  on  the  interests  of 
gynecology,  which  was  due  chiefly  to  the  labors  of  Dr.  H.  R.  Storer 
and  a  few  of  his  colleagues.  Although  the  journal  has  been  discon- 
tinued. Dr.  Storer  having  been  compelled  to  withdraw  from  active 
work  by  reason  of  his  illness,  the  society  continues  to  hold  its  stated 
meetings. 

Other  obstetrical  and  gynecological  societies  have  been  established 
quite  universally.  Where  obstetrical  societies  exist,  gynecology  shares 
with  obstetrics  in  the  attention  which  is  devoted  to  it.  Gynecological 
societies  exist  in  Washington,  Chicago,  Detroit,  Baltimore,  and  sev- 
eral other  cities,  while  the  principal  part  of  the  work  of  the  obstetri- 
cal societies  of  New  York,  Philadelphia,  and  some  other  cities  seems 
to  be  gynecological. 

In  1870  the  American  Medical  Association  passed  resolutions  recom- 
mending that  the  establishment  of  chairs  of  gynecology  separate  from 
that  of  obstetrics  be  more  generally  adopted  by  medical  colleges  and 
schools  throughout  the  country.  The  direct  cause  of  these  resolutions 
was  a  memorial  presented  to  the  association  by  the  Boston  Gynecolog- 
ical Society.  The  Medical  College  at  Castleton,  Vt.,  was  the  first  one 
in  which  special  attention  was  given  to  the  diseases  of  women,  Dr. 
Woodward  lecturing  upon  gynecology  as  well  as  upon  obstetrics.  Prob- 
ably the  first  college  to  found  a  full  professorship  of  gynecology  was 
Dartmouth,  Dr.  Peaslee  being  its  incumbent.  About  the  same  time  Dr. 
H.  R.  Storer  gave  a  full  course  of  lectures  on  gynecology  in  Berkshire 
Medical  College,  Massachusetts,  of  which  institution  he  was  professor 
of  obstetrics  and  diseases  of  women. 


HISTOIilCAL  SKI:T('II   OF  AMERICAN  GYSICCOLOdY.  07 

As  early  as  ls71  tlicrc  wwv.  thirteen  inctlical  (-(tlle^es  in  the  United 
States  in  wliieli  there  were  f"nll  professorships  of  gyneeoloj^y  and  of 
obsti'tries.  Of  this  ninnber,  there  were  seven  schools  with  fnll  profes- 
soi-ships  of  the  diseases  of  women,  incumbents  teaching  nothing  else — 
namely,  the  Albany  Medical  College,  K.  K.  Peaslee ;  Long  Island  Hos- 
pital College,  A.  J.  C.  Skene;  St,  Louis  College  of  Physicians  and 
Surgeons,  M.  A.  Fallen ;  University  of  Louisville,  T.  Parvin ;  the 
Medical  College  of  Ohio,  C.  D.  Palmer;  I'nivcrsity  of  Pennsylvania, 
AVm.  Goodell ;  Detroit  Medical  College,  Edward  AV.  Jenks ;  and  there 
were  eight  professoi'ships  of  gynecology  and  the  diseases  of  children 
combined — namely,  University  of  Xew  York,  F.  D,  Lcnte ;  Mcflical 
College  of  Virginia,  J.  8.  D.  Cullen ;  University  of  Maryland,  W.  D. 
Howard ;  Washington  University,  Baltimore,  M.  P.  Scott ;  Miami 
INIedieal  College,  B.  F.  Richardson ;  Indiana  Medical  College,  T.  B. 
Harvey  ;  Medical  College  of  Evansville,  D,  ]\Iorgan  ;  Louisville  Med- 
ical College,  J.  A.  Ireland.  Since  then  the  authorities  governing 
medical  schools  and  colleges,  realizing  the  importance  of  gynecology, 
have  in  almost  every  instance  added  a  separate  professorship  of  that 
specialty. 

The  foregoing  historical  sketch  of  the  rise  and  progress  of  gynecology 
in  America,  imperfect  though  it  necessarily  be,  can  scarcely  fail  to 
impress  the  reader  with  a  sense  of  the  important  part  which  this 
country  has  borne  in  the  development  of  this  division  of  medicine. 
The  profession  of  America  has,  in  what  it  has  already  accomplished, 
both  demonstrated  a  peculiar  aptness  in  this  particular  field  and  given 
a  guarantee  for  the  future.  With  the  increasing  facilities  which 
increasing  wealth,  and  its  accompaniment  of  growing  freedom  from 
the  mere  money-getting  obligations  resting  on  physicians,  and  the 
enthusiasm,  in  their  work  which  seems  to  an  extent  to  be  peculiar  to 
workers  in  this  field,  the  future  of  gynecology  in  this  country  is  big 
with  hope  and  promise.  It  is  but  fitting  that  the  land  which  furnished 
the  pioneers  should  furnish  also  those  who  shall  carry  on  to  its  fullest 
possible  perfection  the  work  so  auspiciously  begun.  The  mantles  of 
^IcDowell  and  Sims  and  Peaslee  and  the  Atlees  have  fallen  on  worthy 
shoulders,  and  coming  generations  will  accord  to  many  now  living 
places  beside  the  pioneers  who  have  rested  from  their  labors. 


THE  DEVELOPMENT  OF  THE  FEMALE 
GENITALS. 

By  henry  J.  GARRIGUES,  A.  M.,  M.  D., 

New  York. 


As  in  other  departments  of  the  history  of  the  development  of  the 
human  body,  so  our  knowledge  of  the  earliest  stages  of  development 
of  the  female  genitals  is  chiefly  derived  from  the  study  of  the  develop- 
ment of  the  corresponding  parts  in  animals,  especially  the  chicken  and 
the  rabbit. 

The  Wolffian  Ducts.' 

The  first  organs  belonging  to  the  genital  sphere  which  appear  in 
the  male  and  female  are  the  Wolffian  ducts.  In  the  chicken  embryo 
they  appear  during  the  latter  half  of  the  second  day.  There  is  one 
on  either  side.  It  begins  at  the  level  of  the  fourth  or  fifth  protover- 
tebra,  and  extends  rapidly  backward,  so  that  at  the  beginning  of  the 
third  day  it  reaches  the  last  proto vertebra.  At  first  it  is  a  solid  column, 
which  later,  by  the  formation  of  a  cavity  in  its  interior,  is  transformed 
to  a  tube.  On  cross-section  of  embryos  it  makes  its  first  appearance 
as  a  small  protuberance  from  the  lateral  plates  where  they  come  together 
with  the  protovertebral  columns. 

The  posterior  end  of  the  Wolffian  duct  opens  into  that  part  of  the 
allantois  which  is  situated  within  the  body  of  the  embryo,  and  com- 
municates with  the  cloaca,  and  later,  after  the  separation  between  the 
intestinal  and  urogenital  canal  has  taken  place,  into  the  urogenital 
sinus  described  below. 

In  the  rabbit  the  Wolffian  duct  appears  at  the  end  of  the  eighth  or 
the  beginning  of  the  ninth  day,  and  is  developed  in  the  same  way  as 
in  the  chicken.  On  the  eleventh  day  it  opens  into  the  urogenital  sinus. 
Fig.  1  shows  its  situation  between  the  protovertebral  column,  the  lat- 
eral plate,  and  the  descending  aorta.  On  one  side  it  is  yet  a  solid 
string,  on  the  other  it  has  begun  to  be  changed  into  a  canal.  In  Fig. 
2  we  see  it  open  into  the  urogenital  sinus.  Its  lower  end  lies  on  either 
side  of  the  body,  imbedded  in  a  ridge  which  Waldeyer  has  denominated 
"plica  urogenitalis.     According  to  the  same  author,  the  Wolffian  duct  is 

^  Casper  Friedrich  Wolff,  Theoria  Generafinvix,  Berlin,  1759;   "On  the  Development 
of  the  Intestine,"  in  Nov.  Comment.  Acad.  PetropoL,  17GS-69. 
68 


THE   WOLFFTAN  DUCTS. 


69 


not  formed  by  the  porfnration  of  a  solid  column,  but  by  tho  application 
of  tiie  above-mentioned  ])rotuberancc  to  the  lateral  plates,  whereby  first 
u  channel,  and  then  a  closed  tube,  is  formed. 


Transverse  Section  through  the  Median  Part  of  the  Body  of  the  Embryo  of  a  Rabbit  of  nine 
days  and  two  hours  (enlarged  158  times) :  dd,  hypoblast ;  dr,  intestinal  groove ;  ch,  noto- 
chord;  ao,  descending  aorta:;  ww,  protovertebra ;  mr,  medullary  tube;  wn^,  Wolffian  duct; 
dfp,  visceral  division  of  the  mesoblast ;  g,  vessels  in  the  deeper  parts  of  the  visceral  meso- 
blast;  hp,  parietal  mesoblast;  h,  epiblast;  pp,  pleuro-peritoneal  cavity  (KoUiker). 

In  the  female  embryo  of  a  calf  which  measured  one  and  a  half 
inches  in  length  Kolliker  found  the  Wolffian  duct  composed  of  flat 
epithelium  and  a  very  thin  fi- 
brous membrane  not  yet  quite 
separated  from  the  surrounding 
tissue.  It  lay  imbedded  in  a 
thick  layer  of  blastema,  which 
may  be  looked  upon  as  the  fu- 
ture peritoneal  covering  of  the 
A^"olffian  body. 

His  found  it  as  a  cylindrical 
duct  in  a  very  young  human 
embryo,  the  total  length  of 
whose  body  was  only  2.4  milli- 
meters. 

AVhile  in  the  male  sex  the 
^Yolffian  duct  is  destined  to 
play  an  important  part  in  the 
adult  animal,  since  in  course 
of  time  it  forms  the  tail  of  the 
epididymis  and  the  vas  defer- 
ens, in  the  female  sex  of  man 
and  most  animals  it  disappears 
more   or   less   completely,  yet 


Sagittal  Section  through  the  Posterior  Part  of  the 
Body  of  the  Embryo  of  a  Rabbit  of  eleven  days 
and  ten  hours  (enlarged  45  times) :  wy,  Wolffian 
duct;  n,  ureter;  n',  beginning  formation  of  the 
kidney;  ug,  urogenital  sinus;  cl,  cloaca;  hg,  re- 
gion in  which,  in  the  mesial  plane,  the  hind  gut 
opens  into  the  cloaca ;  ed,  postaual  gut ;  a,  anus 
or  fissure  of  the  cloaca ;  «,  tail ;  r,  perineal  fold 
(Kolliker). 


perhaps  not  to  such  an  extent  as  was  formerly  thought.     In  the  swine 


70 


THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


and  the  cow  the  Wolffian  ducts  persist  as  Gartner's^  canals,  so  called 
after  the  Danish  physician  Herman  Treschow  Gartner,  who  discovered 
and  described  them  in  1822  as  a  glandular  organ,  but  Malpighi  had 
already  described  them  in  the  cow  in  1681  in  his  Bissertatio  ad  Jaco- 
bum  Sponium.  The  identity  of  Gartner's  canals  with  the  Wolffian 
ducts  was  first  shown  by  Jacobson.  According  to  Chevau,  these  canals 
run  in  the  cow  in  the  lateral  parts  of  the  vagina  and  extend  six  or 
eight  centimeters  beyond  the  os  uteri.  Their  posterior  end  opens  in 
the  vulva  at  the  side  of  the  urethral  orifice.  They  are  not  known  to 
be  of  any  particular  use,  and  nothing  similar  is  found  in  the  goat  and 
the  sheep.  K5lliker  found  them  as  two  fine  tubules  in  the  anterior 
wall  of  the  uterus  of  the  female  embryo  of  a  cow  which  measured  three 
inches  and  four  lines. 

Milne-Edwards  thinks  that  Gartner's  ducts  are  analogous  to  the  peri- 
toneal tubes  of  crocodiles.  In  these  animals  the  upper  end  opens  into 
the  peritoneal  cavity ;  the  lower  is  either  closed  or  opens  with  a  small 
opening  furnished  with  a  valve  in  the  vulva. 

Beigel  found  Gartner's  ducts  in  a  female  human  foetus  of  seven 
months'  utero-gestation  as  small  epithelial  ducts  situated  laterally  and 
anteriorly  in  the  superficial  layers  of  the  uterus.  K5lliker  found  yet 
distinct  remnants  of  them  in  the  broad  lio-aments  of  full-^rown  human 
fcetuses.     Fischel  has  described  a  case  of  a  newborn  child  in  which 


Fig.  4. 


The  Urethra  laid  open  by  division 
of  its  posterior  or  vaginal  wall ; 
the  tubules  distended  by  probes 
(Skene). 


The  Urethra  laid  open  by  division 
of  its  anterior  wall ;  probes  passed 
into  the  tubules  (Skene). 


one  of  these  ducts  was  found  in  the  vaginal  portion.  Geigel  found 
remnants  of  them  in  the  wall  of  the  vagina  of  a  four  months'  foetus,  but 
not  in  the  uterus,  and  in  two  foetuses  of  six  months  they  had  totally 

^  The  name  is  almost  everywhere  erroneously  spelt  Gartner  or  Gaertner. 


THE   WOLFFIAN  DUCTS.  71 

(Hsajipinired.     Of  late  these  duets  seem  even  to  have  been  fbuud  quite 
f'i'e(|uently,  by  different  observers,  in  the  adult  woman. 

Dr.  Skene  of  l^rooklyn,  N.  Y.,  deseribed  in  the  year  1880  Avhat 
he  ealls  "two  important  jilands  of  the  female  urethra,"  which  by  tlieir 
position  and  structure  seem  to  correspond  with  Gartner's  ducts.  He 
says  that  they  are  found  on  each  side,  near  the  floor  of  the  female 
urethra,  admit  a  No.  1  probe  of  the  French  scale,  and  extend  upward, 
parallel  to  the  long  axis  of  the  urethra,  from  three-eighths  to  three- 
fourths  of  an  inch  in  the  muscular  tissue  below  the  mucous  membrane. 
The  mouths  of  these  tubules  are  found  upon  the  mucous  membrane 
of  the  urethra,  according  to  the  condition  of  the  meatus,  either  one- 
eighth  of  an  inch  inside,  or,  if  the  mucous  membrane  is  everted — which 
is  not  uncommon  in  those  who  have  borne  children — exposed  to  view  on 
either  side  of  the  entrance  to  the  urethra.  The  upper  ends  of  the 
tubules  terminate  in  a  number  of  divisions  which  branch  off  into  the 


Fig.  0. 


\mrethra 


XUBULE 


TUBULE. 


Transverse  Section  of  the  Urethra  about  a  quarter  of  an  inch  from  the  meatus,  showing  the 
cross-cut  of  the  tubules  (Skene). 


muscular  walls  of  the  urethra.  Skene  says  he  has  investigated  these 
tubules  in  more  than  a  hundred  different  subjects,  and  found  them  con- 
stantly present  and  uniform  in  size  aud  location. 

Observations  in  most  respects  similar  to  those  of  Skene  have  been 
made  by  J.  Kocks  of  Bonn.  According  to  him,  these  remnants  of 
Gartner's  ducts  are  found  in  80  per  cent,  of  women.  In  newborn 
children  they  are  relatively  larger,  but  absolutely  smaller,  than  in 
the  adult.     In  old  women  they  very  frequently  disappear.     Micro- 


72 


THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


A,  Vestibule  of  Vulva,  with  meatus  urinarius, 
the  everted  mucous  membrane  showing  the 
entrance  to  the  tubules. 

B,  Meatus  Urinarius,  with  everted  mucous  mem- 
brane and  entrance  to  the  tubules  (Skene). 


scopical  examination  has  failed  to  discover  any  glandular  substance  in 
them. 

The  observations  regarding  the  persistency  of  Gartner's  ducts  have 
A         Fig.  6.  B  lost  somewhat  of  their  apparent 

reliability  by  Dohrn's  investi- 
gations. He  has  for  years  ex- 
amined human  embryos  with 
special  regard  to  these  ducts, 
and  has  come  to  the  conclusion 
that,  as  a  rule,  they  soon  disap- 
pear. According  to  this  author, 
they  are  only  found,  exception- 
ally, in  embryos  from  the  latter 
half  of  pregnancy.  They  reach 
the  uterus  at  a  point  which  later 
corresponds  to  the  internal  os, 
and  become  imbedded  in  the 
outer  edge  of  the  womb.  In  the  vagina  they  are  found  in  the  tissue 
which  surrounds  the  mucous  membrane,  but  lower  down  they  become 
indistinct,  and  they  disappear  totally  before  they  reach  the  orifice  of 
the  urethra.  Dohrn  thinks  that  what  has  been  described  as  persistent 
Gartner's  ducts  are  only  folds  of  the  m^ethra.  At 
the  posterior  part  of  the  urethral  orifice  are  normally 
found  two  such  invaginations  of  the  urethra,  which 
extend  upward  as  more  or  less  deep  pockets. 

Wassilieif,  who  has  described  the  two  tubuliform 
glandular  formations  at  the  entrance  of  the  female 
urethra  in  a  Russian  work  in  the  same  year  as  Skene 
— that  is,  two  years  before  the  article  of  Kocks — does 
not  admit  the  correctness  of  Dohrn's  criticisms.  He 
has  repeatedly  examined  these  tubules  on  sections  made 
after  injection  with  Berlin  blue,  and  found  them  lined 
with  an  epithelium  very  much  like  that  of  the  prostate, 
and  entirely  diiferent  from  that  in  the  adjoining  part 
of  the  urethra. 

Carl  Rieder  found  Gartner's  ducts  only  persisting 
in  eight  out  of  forty  cases. 

From  the  results  of  these  various  investigations 
we  may  conclude  that  Gartner's  ducts,  as  a  rule,  dis- 
appear in  the  second  half  of  pregnancy,  but  that  they  exceptionally  per- 
sist even  in  the  adult  woman. 

That  the  upper  parts  of  these  ducts  occasionally  persist,  and  may 
give  rise  to  vaginal  cysts,  there  is  scarcely  any  doubt.  I  have  myself 
examined  a  cyst  of  this  kind  extirpated  by  Dr.  R.  Watts  of  this  city, 


Fig.  7. 


A  Tubule  laid  open, 
and  showing  the 
branches  at  the  up- 
per end    (Skene). 


TIIK    WOLFFIAN   BODIES. 


73 


and  both  the  clinical  observation  that  the  cyst  at  its  upper  end  liad  a 
tubulit(»rm  continuation  throuijh  which  a  uterine  sound  went  uj)  to  the 
iliac  I'nssa,  and  tlie  liistological  composition  of  the  sac,  which  cor- 
respondci^l  with  that  of  the  vas  deferens,  determined  me  to  tai<c  it  to  he 
a  dilated  Gartner's  duct.^ 


The  Wokffian  Bodies. 
Shortly  after  the  Wolffian  ducts — in  the  chicken  at  the  end  of  the 
second  and  the  beginning  of  the  third  day,  in  the  rabbit  on  the  ninth 

and  tenth  day — appear  the  so-called  Wolff- 
ian bodies.  His  found  them  in  a  human 
foetus  of  the  first  month  whose  body  was 
2.6  millimeters  long.  Like  the  ducts,  they 
are  placed  symmetrically  one  on  either  side 
of  the  vertebral  column.  At  the  period 
of  their  highest  development  they  extend 
as  two  long  prismatic  ])odies  from  the  level 
of  the  rudimentaiy  diaphragm  Iom*  down 
into  the  pelvis.  At  their  upper  end  they 
are  bound  to  the  lower  surface  of  the  dia- 
phragm by  a  small  filament  which  Kol- 
liker  calls  their  "  diaphragmatic  ligament," 
and  which  Waldeyer  explains  to  be  the 
upper  end  of  ^liiller's  ducts,  of  which  we 
soon  shall  speak.  At  their  lower  end  they 
are  fastened  to  the  inguinal  region  bv  a 
filament  which  Kolliker  calls  their  "  in- 
guinal ligament,"  and  which  in  the  course 
of  time  becomes  the  gubemaculum  testis 
in  the  male  and  the  round  ligament  in  the 
female  sex.  The  bodies  are  bound  to  the 
posterior  wall  of  the  abdominal  cavity-  by 
a  broad  and  low  mesenterv.  They  are  so 
large  that  they  fill  the  whole  hollow  of  the 
posterior  wall,  leaving  only  a  narrow  fissure 

Human  Embryo  of  thirty-five  days  rfront  vie-n-)-.  3.  left  external  nasal  process ;  4,  superior  max- 
illarj-  process ;  5.  lower  maxillary  process ;  s,  tongrue  ;  6,  aortic  bulb  ;  6',  lirst  permanent  aortic 
arch ;  h",  second  aortic  arch ;  h",  third  aortic  arch,  or  ductus  Botalli ;  ij.  the  1r\vo  filaments  to 
the  right  and  the  left  of  this  letter  are  the  pulmonary  arteries,  which  begin  to  be  developed ; 
c.  the  stem  of  the  superior  cava  and  right  azygos  vein :  c',  the  common  venous  sinus  of  the 
heart :  c",  the  common  stem  of  the  left  vena  cava  and  left  azygos :  o'.  left  auricle  of  the  heart ; 
I',  right,  r',  left  ventricle  ;  ae.  lungs ;  e,  stomach  :  j.  left  omphalo-mesenteric  vein ;  s,  contin- 
uation of  the  same  behind  the  pylorus,  which  becomes  afterward  the  vena  porta;  x,  vitello- 
intestinal  duct :  a,  right  omphalo-mesenteric  artery  ;  m.  Wolffian  body ;  i,  gut ;  n,  umbilical 
artery ;  w.  umbilical  vein :  8.  tail ;  9,  anterior,  10.  posterior  limb.  The  liver  has  been  removed. 
The  white  band  at  the  inner  side  of  the  Wolffian  body  is  the  genital  gland,  and  the  two 
white  bands  at  its  outer  side  are  the  Miillerian  and  the  Wolffian  ducts  (Kolliker,  after  Coste). 

^  "Trans,  ^*ew  York  Obst.  Soc,"  Am.  Journ.  of  OhsL,  October,  1881. 


74 


THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


on  either  side.  In  the  inner  one  of  these  fissures  is  later  developed  the 
genital  gland  ;  in  the  outer  one  runs  the  Wolffian  duct,  and  later  like- 
wise the  Miillerian  duct.  Their  posterior  surface  rests  on  the  blastema 
(in  which  later  the  kidneys  are  developed),  on  the  aorta,  and  on  a  large 
vein  which  takes  up  the  blood  coming  from  the  bodies. 

The  Wolffian  bodies  are  formed  from  the  lateral  plates — or,  more 
precisely,  from  the  cellular  lining  of  the  peritoneal  cavity  — as  a  long 
row  of  small  pear-shaped,  solid  bodies,  which  soon  become  separated 
from  the  endothelium  of  the  peritoneum  and  become  hollow,  in  which 
stage  they  are  called  segmental  vesicles.  These  vesicles  are  in  contact 
with  the  Wolffian  duct,  and  soon  the  thin  layer  which  separates  the  two 


Fig.  9. 


0 


III  ,  \  y'l   d 


''^/    /,     .      "f"u 


\\    fill    ^,,1^^. 


The  Genital  and  Urinary  Organs  of  the  Embryos  of  Cattle :  1,  from  a  female  embryo  V/,  inches 
long  (double  size) :  w.  Wolffian  body  ;  wg,  the  Wolflfian  and  the  Miillerian  ducts ;  i.  Inguinal 
ligament  of  the  Wolffian  body;  o,  ovary  with  an  upper  and  lower  peritoneal  fold;  n,  kid- 
ney ;  nn,  suprarenal  body ;  g,  genital  cord,  composed  of  the  united  Wolffian  and  Mullerian 
ducts.  2,  from  a  male  embryo  2]4  inches  long  (nearly  three  times  natural  size) :  one  of  the 
testicles  has  been  removed.  Letters  as  in  fig.  1,  and,  besides,  m,  Mliller's  duct;  m',  upper 
end  of  the  same ;  h,  testicle ;  h',  lower  ligament  of  the  testicle :  h",  upper  ligament  of  the 
testicle ;  d,  diaphragmatic  ligament  of  the  Wolffian  body ;  a,  umbilical  artery ;  v,  bladder. 
3,  from  a  female  embryo  (enlarged  nearly  three  times) :  letters  as  in  figs.  1  and  2,  and,  be- 
sides, t,  opening  at  the  upper  end  of  Miiller's  duct;  o',  lower  ovarian  ligament;  m, thickened 
part  of  the  Mullerian  duct,  which  later  becomes  the  uterine  horn  (Kolliker). 


cavities  is  absorbed,  so  that  henceforth  the  vesicles  appear  as  invagina- 
tions from  the  duct,  which  as  to  origin  they  are  not.  These  grow  rapidly, 
and  are  transformed  into  long  convoluted  tubes,  which  in  the  inner  part 
of  the  Wolffian  bodies  connect  with  arterial  tufts  in  a  similar  way  as 
the  uriniferous  ducts  of  the  permanent  kidneys  combine  with  arterial 
convolutions  to  form  the  Malpighian  tufts. 

The  Wolffian  body  is  in  the  male  developed  into  the  epididymis  and 


Tllh'   WOLFFIAN  BODIES. 


76 


Giralclez's'  body  (Fiji".  10).      In  the  f'cinalc  sex  these  two  parts  are  less 
prominent.     Corres])on(lin^'  to  tlie  epididymis  we  have  Roseniniiller's^ 


Fio.  10. 


<!«?«« 


Fig.  11. 


....JT 


Fig.  10.— Internal  Genital  Organs  of  a  Female  Human  Foetus  zy,  inches  long  (enlarged  10 
times):  O,  ovary;  Z,  Fallopian  tube;  O.abcl,  abdominal  opening  of  the  tube;  E,  epo- 
ophoron  (upper  part  of  the  Wolflian  body) ;  U,  paroophoron  (lower  part  of  the  Wolffian 
body) ;  Y,  Wolffian  duct,  the  lower  part  of  which  disappears,  but  its  place  is  marked  by 
thickened  tissue  that  combines  with  the  thickened  connective  tissue  surrounding  the 
tube;  3Tp,  Malpighian  bodies  (Waldeyer). 

Fig.  11.— Internal  Genital  Organs  of  a  Male  Human  Foetus  2]4  inches  long  (enlarged  8  times) : 
//,  testicle  ;  E,  epididymis  (the  upper  part  of  the  Wolffian  body) ;  U,  paradidymis,  or  Giral- 
dez's  organ  (the  lower  part  of  the  Wolffian  body) ;  O,  bundle  of  connective  tissue  with  blood- 
vessels; y,  vas  deferens  (Wolffian  duct)  (Waldeyer). 


organ,  or  the  parovarium,  and  Giraldez's  organ  is  represented  by  stray 
tubes  found  in  the  broad  ligament  between  the  parovarium  and  the 
uterus  (Fig.  11).  They  are  filled  with  epithelial  cells  and  detritus,  and 
often  give  rise  to  the  formation  of  cysts.  I  have  frequently  seen  small 
cysts  situated  between  the  parovarium  and  the  uterus.  It  is  therefore 
not  an  improvement  when  of  late  years  some  authors  substitute  the 
term  "  parovarian  cyst "  for  the  older  term  "  cyst  of  the  broad  liga- 
ment." When  a  cyst  forms  in  any  part  of  the  broad  ligament  and 
acquires  surgical  proportions,  it  will  scarcely  be  possible  to  prove  that 
it  has  been  developed  in  the  parovarium.  The  term  **cyst  of  the 
Wolffian  body,"  on  the  other  hand,  would  probably  be  more  correct, 
although  there  is  a  possibility  that  any  small  agglomeration  of  cells 
belonging  to  the  native  germ -epithelium,  which  will  be  described  later, 
may  become  the  starting-point  of  an  extra-ovarian  cyst. 

In  order  to  sho^v  the  homology  between  the  named  organs  in  the  two 
sexes,  Waldeyer  has  proposed  to  call  Giraldez's  organ  "  parepididymis," 

^Giraklez,  "  Recherche?  anatomiqnes  snr  le  corps  innoniine,"  in  BrowH' S^quard's 
Journ.  de  I'Anat.  el  de  la  Pln/iiioL,  1861. 

^Eosenmiiller,  Qucedam  de  ovariis  embryonum  etfoetimm  humanorum,  Lipzire,  1802. 


76 


THE  DEVELOPJiUENT  OF  THE  FEMALE  GENITALS. 


or,  shorter,  "  paradidymis,"  Rosenmiiller's  organ  "  epoophoron,"  ^  and 
the  tubules  between  this  organ  and  the  uterus  "  paroophoron."  ^ 


The    Ovaries.  ^ 

The  sexual  glands  are  originally  entirely  alike  in  the  two  sexes. 
They  make  their  first  appearance  very  soon  after  the  Wolffian  bodies — 
in  the  chicken  on  the  fifth  day,  in  the  rabbit  on  the  twelfth  or  thirteenth, 
in  man  in  the  fifth  or  sixth  week.  In  the  latter  they  begin  as  a  white 
streak,  called  "the  genital  ridge,"  on  the  inner  side  of  the  Wolffian 
bodies.  This  streak  extends  almost  as  far  as  the  bodies  themselves, 
and  is  in  close  contact  with  them.  How  it  is  formed  in  man  is  not 
known,  but  in  chickens  the  process  has  been  studied  step  by  step.  In 
these  animals  the  genital  glands  originate  as  a  thickening  of  the  epi- 
thelium of  the  inner  part  of  the  Wolffian  bodies.  This  part  of  the 
peritoneal  epithelium  diifers  from  the  other  by  being  composed  of 
columnar  cells,  and  as  it  forms  the  substance  of  which  the  Fallopian 
tubes,  the  ovaries,  and  the  ova  are  formed,  Waldeyer  has  designated  it 
as  the  "  germ-epithelium  "  (Keimepithel). 

It  is  not  before  the  end  of  the  second  month  that  the  ovaries  begin 
to  differ  from  the  testicles  in  man,  the  latter  becoming  broader  and 


Fig.  12. 


Perpendicular  Section  through  the  Ovary  of  a  Human  Foetus  of  thirty-two  weeks  (Hartnack,  s) : 
a,  epithelium ;  b,  b,  cells  in  the  epithelium  which  become  primordial  ova ;  c,  prolongations 
of  connective  tissue  growing  into  the  epithelial  layer;  d,  d,  cluster  of  epithelial  cells  in  the 
process  of  being  imbedded ;  e,  e,  primordial  follicles  with  a  wall  formed  of  narrow  connec- 
tive-tissue cells ;  /,  groups  of  imbedded  epithelial  cells,  some  of  which  are  larger  than  the 
others  (primordial  ova);  g,  granular  cells  (His). 

shorter,  while  the  former  retain  their  lengthy  shape,  and  in  the  ninth 
or  tenth  Aveek  take  a  more  oblique  direction. 

Another   earlv  sim  of   distinction    between   the   testicles   and   the 


1  'E-i,  upon  ;  'wov,  egg ;  0£pw,  I  carry. 
^  Latin,  ovum,  egg. 


Ilapd,  beside. 


THE    OVARIES. 


11 


ovaries  i.s  that  the  latter  liave  a  imich  more  developed  eoliimnar 
epithelium.  In  the  ehicl^en  this  diflereiice  is  j)resent  as  early  as  the 
end  of  the   lirst   wfek. 

Even  before  the  distinetion  between  the  sexual  glands  takes  place 
they  are  fastened  to  the  Wolffian  bodies  by  means  of  a  small  fold  of 
the  peritoneum,  which,  according  to  the  sex,  is  called  "  mesorchium  " 
or  "  mesoarium."  From  the  upper  end  of  the  reproductive  gland  a 
small  ligament  runs  to  the  diaphragmatic  ligament  of  the  Wolffian 
body,  and  the  lower  end  is  bound  by  another  ligament  to  the  Wolffian 
duct  opposite  the  starting-point  of  the  inguinal  ligament  of  the  Wollf- 
ian  body  (Fig.  12). 

Fig.  13. 


Perpendicular  Section  through  the  Ovary  of  a  Bitch  of  six  months  (Hartnack,  ?):  a,  epithe- 
lium; 6,  epithelial  pouch,  opening  on  the  surface;  c,  larger  group  of  follicles;  d,  ovarian 
tube  containing  ova ;  e,  oblique  and  transverse  sections  of  ovarian  tubes  (Waldeyerj. 

Originally  both  ovaries  have  about  the  same  size,  but  from  about  the 
ififth  month  of  gestation  the  left  ovary  is  left  considerably  behind  as  to 
development.  In  the  eighth  week  their  length  is  2.5  to  3  millimeters 
(Puech).  Meyer  furnishes  the  following  figures  as  indicating  the  length 
of  both  ovaries  of  human  foetuses  at  different  periods,  the  figures  being 
the  average  of  several  measurements  : 


Age  in  weeks. 

10. 

15. 

20. 

24. 

28. 

.32. 

35. 

40. 

Length  of  the  ovaries  /  right  .... 
in  millimeters           (^  left     .... 

3.8 
3.7 

5.0 
5.0 

Ill 

12 

12J 
11 

12f 

16| 
13^ 

16J 

m 

111 

Puech  mentions  likewise  the  greater  length  of  the  right  ovary,  but 
the  average  difference  in  forty  cases  was  only  about  one  and  a  half 
millimeters,  the  average  length  of  the  right  being  19.8  millimeters; 
of  the  left,  18.2. 

During  the  first  two-thirds  of  gestation  the  uterus  and  the  ovary 
keep  almost  equal  pace  as  to  size,  but  from  the  end  of  the  seventh 


78 


THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


month  the  uterus  increases  much  more  rapidly.  In  the  following  list^ 
taken  from  Meyer,  the  length  only  is  considered,  and  that  of  the  ova- 
ries is  the  average  found  for  the  two  : 

uterus.  Ovaries. 

10th  week —  mm.         3.8  mm. 

15th  "  5J  5 

20th  "  ^  12 

24th  "  llj  llf 

28th  "  12J  13J 

32d   "  19  15J 

36th  "  .24  15 

40th  "  28  19 

The  shape  of  the  ovary  varies  very  much  at  different  periods.  At 
first  it  is  a  long  flat  body  ;  later  it  grows,  especially  at  the  edges,  so  that 
a  cross-section  presents  the  figure  of  a  bean  or  a  mushroom,  as  in  Fig. 

Fig.  14. 


Transverse  Section  through  the  Ovary  of  a  Human  Embryo  of  three  months  (enlarged  43 
times) :  a,  mesoarium ;  a',  stroma  of  the  hilus  (medullary  substance) ;  6,  glandular  tissue 
(cortical  substance)  (KoUiker). 


14.  About  the  middle  of  gestation  the  lips  at  the  hilus  disappear,  and 
the  line  of  insertion  of  the  mesoarium  approaches  the  lower  and  pos- 
terior edge,  so  that  a  cross-section  presents  a  pear-shaped  appearance. 
In  the  foetus  as  well  as  in  the  infant  the  surface  of  the  ovaries  shows 
impressions  of  the  surrounding  organs.  It  is  first  at  the  end  of  the 
second  year  that  the  organ  has  become  resistant  enough  to  maintain 
an  even  surface  independent  of  the  contiguous  pails. 

The  ovary  is  subject  to  a  descent  similar  to  that  of  the  testicle.  It 
takes  place  soon  after  the  tenth  or  eleventh  week,  so  that  the  ovary  at 
the  end  of  the  fifteenth  week  is  found  almost  in  the  same  place  as  later.. 


THE  OVARIES.  79 

Yet  even  in  newborn  children  and  shortly  .liter  hirtli  we  find  the  ovaries 
sitnatc'd  above  the  ile()-[)eetineal  line.  As  a  I'ule,  tlie  ovaries  descend 
into  the  trne  j)elvis  dnrinji;  the  first  two  or  three  months  after  the  birth 
of  the  child  (Kolliker),  The  descent  consists  chiefly  in  a  change  of 
diriH-tion,  and  not  in  a  trne  change  of  the  distance  between  the  ovaries 
and  the  nterns.  At  the  earliest  period  the  lower  end  of  the  ovary  is 
fonnd  oi)])osite  the  starting-point  of  the  ronnd  ligament  of  the  nterns. 
JNIost  of  the  api)arent  descent  is  dne  to  a  disproportion  in  the  growth 
of  the  parts  sitnated  above  and  below  the  ovaries.  The  shrinking 
of  the  ronnd  ligaments,  which  are  composed  of  cellular  elements 
and  much  fibrillar  tissue — a  shrinking  analogous  to  that  which  takes 
place  in  cicatricial  tissue — seems  likewise  to  be  at  work,  but  to  be  of 
subordinate  importance.  By  the  change  in  direction  referred  to  the 
upper  end  turns  outward  and  sinks  considerably  downward  ;  the  lateral 
edge  becomes  the  superior  or  free  edge ;  the  mesial  edge  becomes  the 
lower ;  the  ventral  or  anterior  surface  is  turned  inward  to  the  mesial 
line ;  the  dorsal  or  posterior  surface  is  turned  outward  to  the  side  of 
the  pelvis  (Kolliker). 

The  relations  to  the  Fallopian  tubes  are  changed  in  such  a  way  that 
the  ovary,  instead  of  being  situated  on  the  inner  or  mesial  side  of  the 
Miillerian  duet,  finally  lies  behind  and  below  the  Fallopian  tube.  The 
rio-ht  ovary  is  from  the  tenth  week  of  gestation  placed  lower  and  nearer 
the  uterus  than  the  left. 

At  the  upper  end  of  the  foetal  mesoarium  enter  the  ovarian  vessels 
from  the  posterior  abdominal  wall,  and  extend  downward,  enclosed  in  a 
particular  fold  of  the  peritoneum,  which  exhibits  a  free  lateral  edge  and 
in  course  of  time  becomes  the  infundibulo-pelvic  ligament,  extending 
from  the  fimbriated  end  of  the  Fallopian  tube  to  the  side  wall  of  the 

pelvis. 

To  the  lateral  side  of  the  mesoarium  is  attached  the  mesosalpinx, 
or  mesentery  of  the  Fallopian  tube.  In  older  embryos  it  is  stretched 
out  behind  the  ovary  as  a  fine  membrane,  the  free  outer  edge  of  which 
surrounds  the  Fallopian  tube.  In  a  previous  stage  this  membrane 
formed  the  peritoneal  covering  of  the  Wolffian  body,  and  contains  the 
remnants  of  this  body,  especially  the  parovarium. 

The  inner  (lower,  anterior)  end  of  the  ovaries  is  bound  tc  the  uterus 
by  means  of  the  ovarian  ligament,  which  is  a  continuation  of  the  meso- 
arium. At  the  middle  of  gestation  these  inner  ends  lie  pretty  near  one 
another.  They  rest  on  the  ureters  and  the  umblical  arteries,  while  the 
outer  (up]3er,  posterior)  part  of  the  ovaries  is  placed  in  front  of  the  ex- 
ternal iliac  vessels.  The  broad  ligament  cannot  be  said  to  exist  yet,  the 
uterus  filling  the  whole  cavity  of  the  true  pelvis.  AVhat  starts  from  its 
sides  is  nothing  but  the  already-mentioned  formations — namely,  the 
mesoarium,  the  mesosalpinx,  and  the  round  ligament ;  which  latter,  as 


80 


THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


we  have  seen  above,  is  originally  a  ligament  belonging  to  the  Wolffian 
body,  and  only  enters  into  connection  with  the  uterus  after  the  destruc- 
tion of  those  bodies, 

"While  the  tubes,  and  likewise  that  part  of  the  uterus  which  is  situ- 
ated in  the  peritoneal  cavity,  are  covered  all  over  with  peritoneum,  the 


Fig.  15. 


Transverse  Section  through  the  Ovarian  Region  of  a  Human  Embryo  of  five  months,  lower 
surface  seen  from  above  (enlarged  3  times) :  oi,  os  ilium ;  s,  sacrum ;  mo.  mesoarium  and 
the  hilus  of  the  ovary,  bounded  by  two  lips;  o,  cut  surface  of  the  ovary;  r,  free  ventral 
surface  of  the  ovary  or  lateral  part  of  the  ventral  surface  ;  t,  tube ;  mt,  mesentery  of  the 
tube  (later  the  ala  vespertilionis) ;  r,  rectum ;  lu;  ureter ;  au,  umbilical  artery ;  ie,  external 
iliac  vessels ;  nc,  anterior  crural  nerve  (KoUiker). 

ovaries  are,  as  it  were,  lodged  in  two  holes  of  the  peritoneum.  Only 
quite  near  the  hilus  have  they  a  sheath  of  that  membrane. 

The  formation  of  the  ova  and  Graafian  follicles  ^  has  especially  been 
elucidated  by  Waldeyer,  and  his  views  have  with  slight  modifications 
been  corroborated  by  H.  jSIeyer,  the  most  recent  investigator  of  the 
subject,  and  by  Allen  Thomson.  At  the  earliest  stage  we  have  seen 
the  ovary  to  be  represented  by  a  streak  composed  of  cells  developed 
from  the  peritoneal  covering  of  the  Wolffian  body.  Very  soon  a  pro- 
tuberance of  connective  tissue  makes  its  way  from  behind  into  this 
cell-heap.  These  two  different  parts  are  the  beginning  of  the  two 
substances  which  go  to  build  up  the  ovarv^,  the  connective  tissue  form- 
ing the  stroma ;  the  cells,  the  parenchyma  or  glandular  part ;  but  in 
the  ensuing  development  these  two  elements  become  most  intimately 
interwoven.  The  stroma  sends  out  between  the  cells  prolongations 
which  separate  them  into  groups,  and  grow  together  over  them,  so  as 

^  Begnier  de  Graaf,  De  Mulkrum  organis  generationi  inservientibus,  Leyden,  1672. 


THE  OVARIES. 


81 


to  form  a  layer  of  connective  tissue  above  them ;  but  simultaneously 
new  layers  of  cells  are  formed  outsitlc  (»f  the  first  border-line,  wliich 


Fig.  1G. 


Y\<:.  1 


^f^. 


&  n 


Fig.  16.— Ovary  of  a  Human  Foetus  of  ten  or  eleven  weeks :  a,  superficial  stratum  of  cells ;  b, 
layer  of  connective  tissue;  c,  trabecule  of  connective  tissue,  the  cells  having  been  removed; 
d,  mesoarium  (Meyer). 

Fig.  17.— Part  of  the  same  Ovary,  near  the  surface,  seen  -with  higher  power:  v,  natural  size 
of  the  ovary. 

again  l^ecome  divided  into  groups  by  new  prolongations  of  the  stroma. 
The  chief  direction  of  the,se  prohjugations  is  a  radial  one  from  the  hilus 

Fig.  18. 


From  a  Fcetus  of  sixteen  weeks.    The  formation  and  separation  of  ova  (Meyer). 

to  the  surface.     At  an  earlier  stage  they  are  entirely  irregular,  and  do 
not  form  closed  cavities,  but  an  irregular  system  of  meshes  and  anas- 

FiG.  19. 


From  a  Foetus  of  twenty-eight  weeks.    In  some  places  is  already  seen  the  permanent  epithe- 
lium, composed  of  a  single  layer  (Meyer). 

tomosing  tubes,  much  like  those  seen  in  a  sponge.     At  the  surface  is  a 
particular  zone  composed  of  several  layers  of  cells,  between  which  are 

Vol.  I.— 6 


82 


THE  DEYELOPMENT  OF  THE  FEMALE  GENITALS. 


Fig.  20. 


From  a  Foetus  of  thirty-six  weeks.    The  single  epithelial  layer  is  interrupted  by  the  intercala- 
tion of  a  belated  primordial  ovum  with  its  follicular  epithelial  cells  (Meyer). 

Fig.  21.  Fig.  22. 


Three  Graafian  Follicles  from  the  Ovary 
of  a  Newborn  Girl  (enlarged  350  times) : 
1,  natural  condition;  2,  treated  with 
acetic  acid:  a,  structureless  mem.brane 
of  follicles;  6,  epithelium  (membrana 
granulosa) ;  c,  yolk  ;  d,  germinal  vesicle, 
with  germinal  macula;  e,  nuclei  of  the 
epithelial  cells;  /,  vitelline  membrane 
(very  fine)  (Kolliker). 

found  fine  prolongations  from 
the  stroma ;  and  this  zone  is 
separated  from  the  rest  of  the 
parenchyma  by  a  fine  layer  of 
connective  tissue  (Fig.  16). 

From  the  end  of  the  sixth 
month  the  surface  begins,  in 
some  places,  to  form  a  single 
layer  of  epithelial  cells  (Fig. 
19),  and  in  the  newborn  girl 
the  whole  ovary  is  covered  with 
such  a  single  layer  of  low  col- 
umnar cells,  under  which  lies  a 
more  or  less  thick  layer  of  con- 
nective tissue,  the  so-called  albu- 

Part  of  Section  from  surface  to  hilus  of  Ovary  from  Girl  three  days  old  :  single  layer  of  epithe- 
lium yet  in  connection  with  a  cluster  of  primordial  ova.  All  ova  have  disappeared  from 
the  surface.  A  broad  layer  of  stroma  separates  in  most  places  the  epithelium  from  the  fol- 
licular zone.  The  farther  we  go  from  the  surface  toward  the  hilus,  the  fewer  ova  are  there 
in  one  nest,  until  finally  there  is  only  one  in  its  primary  follicle,  n,  natural  size  of  the 
whole  ovary  (Meyer). 


THE  OVARIES.  83 

ginoa  (I^'it!;.  -1).  This  is  by  no  moans  a  separate  membrane,  but  only 
a  sonu'w  hat  dcnsor  ])art  of  tiu'  ovarian  stroma.  (Figs.  18-20  show  the 
gratUial  cliaiige  of  the  surface.) 

In  the  mean  time  the  prolongations  extending  from  the  hihis  to  the 
surface  have  grown  in  thickness,  length,  and  width,  and  new  prolonga- 
tions have  grown  from  the  walls  of  the  older  meshes,  dividing  the  ceil-, 
groups  into  smaller  and  smaller  compartments,  until  finally  one  large 
cell  with  one  or  m<jro  smaller  ones  is  entirely  enclosed  in  a  cavity  formed 
by  the  stroma  (Fig.  20).  These  large  cells,  containing  a  large  nucleus, 
are  the  future  ova,  and  are  called  primordial  ova.  The  compartment 
in  which  they  are  found  imbedded  with  the  small  epithelial  cells  are 
called  primary  follicles  (Figs.  18,  19).  The  smaller  cells  increase  in 
number  and  form  several  layers.  A  fissure  appears  between  these 
layers,  and  a  liquid  accumulates  in  the  interstice,  forming  the  begin- 
ning of  the  liquor  folliculi.  The  outer  layers  form  the  epithelium  of 
the  Graafian  follicles,  the  so-called  membrana  granulosa;  the  inner 
continue  to  surround  the  ovum  and  form  the  discus  proligerus,  or,  as 

Fig.  23. 


Graafian  Follicle  from  a  Girl  seven  months  old  (enlarged  220  times ;  natural  size,  0.351  mm.) : 
a,  epithelium  (membrana  granulosa i  detached  from  the  fibrous  membrane  ;  h,  discus  prolig- 
erus or  cumulus  ovigerus,  situated  far  away  from  the  surface.  It  contains  the  ovum,  on 
which  the  zona  pellucida  and  the  germinal  vesicle  are  visible.  The  surrounding  fibrous 
membrane  of  the  follicle  is  not  yet  separated  into  two  layers,  and  there  is  no  distinct  line 
of  demarkation  between  it  and  the  stroma  (KoUiker). 

Kolliker  more  graphically  designates  it,  the  cumulus  ovigerus — i.  e.  the 
heap  containing  the  ovum  (Fig.  23).  At  what  time  this  formation  of 
the  true  Graafian  follicles  normally  takes  place  is  not  yet  decided.  Some 
have  found  them  in  the  newborn  child,  others  only  after  the  age  of  two 
years  and  a  half. 


84  THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 

At  first  the  primordial  ovum  is  a  simple  protoplasmic  body  without 
any  membrane,  the  zona  pellucida  (Fig.  24)  appearing  after  the  forma- 
tion of  the  Graafian  follicle  is  completed. 

The  fibrous  membrane  of  the  follicle  is  formed  by  a  differentiation 

of  the  surrounding  stroma.     After  the  completion  of  the  follicles  they 

can  easily  be  enucleated  from  the  surrounding  stroma,  showing  that  the 

connection  with  the  latter  has  been  loosened.    This 

Fig.  24.  seems  to  be  due  to  the   formation  of   numerous 

lymph-spaces  in  .the  connective  tissue  surrounding 

the  fibrous  membrane  of  the  follicles. 

As  here  described,  the  ova,  the  surface  epithelium 
of  the  ovaries,  and  the  epithelium  lining  the  inside 
of  the  Graafian  follicles  have  all  one  and  the  same 
origin ;  but  it  might  be  proper  to  add  that  while 
Human  Ovum  from  a  me-  ^H  observers  havc  Corroborated  Waldeyer's  doctrine 

dium-sized  Follicle  (en-  i       r>  •  r>     i  i       • 

larged  250  times) :  a,  as  to  the  formation  01  the  ova,  there  obtams  some 
I™SSTrnmTt  difference  of  opinion  as  to  the  origin  of  the  epithe- 
between  the  yolk  and  Hum  of  the  folliclcs,  the  so-callcd  membraua  granu- 

the  zona  pellucida;   c,    i  -ttti  -i     -ttt-  it  •  -x  x1  •    ■ 

germinal  vesicle  with  ^osa.  VVhile  Waldeyer  gives  it  the  same  origin  as 
germinal  spot  (K61-  the  ova — namely,  the  germ-epithelium  covering  the 
surface  of  the  ovaries — Foulis  believes  it  is  formed 
from  the  stroma  of  these  glands.  According  to  Kdlliker,  the  process 
is  much  more  complicated.  In  that  part  of  the  ovary  which  is  situated 
nearest  to  the  hilus  are  found  cords  composed  of  small  cells  and  canals 
lined  with  columnar  epithelium,  which,  like  several  other  microscopists, 
Kolliker  takes  to  be  remnants  of  the  Wolffian  body.  But  he  has  found 
that  these  so-called  medullary  cords  come  in  contact  with  the  primordial 
ova  which  are  exclusively  found  in  the  more  superficial  layers  of  the 
ovary,  and,  according  to  him,  they  surround  these  ova  and  furnish  the 
membrana  granulosa  of  the  Graafian  follicle. 

The  great  simplicity  of  Waldeyer's  theory,  and  new  observations  in 
lower  animals  by  other  embryologists,  would  seem  to  give  that  theory 
the  preference,  according  to  which  the  epithelium  of  the  follicle  and 
the  ovum  which  it  encompasses  are  derived  from  the  same  source ;  and 
recently  this  view  has  been  corroborated  by  the  investigations  of  Meyer 
in  human  embryos. 

It  is  very  likely,  although  not  yet  positively  proved,  that  the  cells 
which  are  destined  to  become  ova  after  being  surrounded  by  stroma 
multiply  by  division.  This  would  constitute  a  second  source  of  the 
enormous  number  of  ova  contained  in  the  ovaries,  which  has  been 
evaluated  by  Henle  to  thirty-six  thousand  in  each  gland  (Fig.  25). 
The  formation  of  ova  on  the  surface  of  the  ovaries  ceases  almost 
entirely  from  the  time  they  are  covered  with  a  single  layer  of  epi- 
thelium— that  is  to  say,  about  the  end  of  the  seventh  month — but  it  is 


THE  MVLLERIAN  DUCTS. 


85 


not  unlikely  that  the  formation  of  new  ova  by  division  may  go  on  much 
longer. 

From  the  time  of  the  birth  of  the  eliild  to  that  of  puberty  the  ovaries 
simply  grow  in  size  and  beeome 
smoothed  and  rounded  off.  In 
children  from  six  to  eleven  years 
old  the  average  measures  of  the 
rio'ht  ovarv  are  —  length,  26.7 
millimeters ;  height,  9.0 ;  thick- 
ness, 4.4  ;  the  left,  length,  24.0  ; 
height,  8.4  ;  thieloiess,  4.6.  In 
girls  of  thirteen  to  fourteen 
years  the  average  measures  are 
— right  ovary,  length,  29.6 ; 
height,  15;  thickness,  10;  left, 
length,  25  ;  height,  14  ;  thick- 
ness, 9.3  (Puech).  At  the  age 
of  puberty  a  new  life  begins  in 

the  organs  by  the  periodical  development  and  rupture  of  the  Graafian 
follicles,  by  which  the  ova  are  set  free.  (For  the  particulars  of  this 
process  we  refer  the  readers  to  works  on  physiology  and  anatomy.) 


From  a  Human  Embrj-o  of  six  months  (enlarged 
400  times) ;  1,  two  primordial  ova  surrounded  by  a 
common  layer  of  epithelium,  one  of  which  has  a 
prolongation  by  means  of  which  it  probably  was 
attached  to  another  ovum,  as  in  2,  where  two  pri- 
mordial ova  are  linked  together  by  means  of  a 
band  of  protoplasm,  the  whole  surrounded  by  one 
epithelial  layer.  3,  primordial  ovum  with  two 
nuclei  (germinal  vesicles)  (Kolliker). 


The  Mullerian  ^  Ducts. 

In  no  part  of  our  study  of  the  development  of  the  female  genitals 
are  we  more  forcibly  reminded  of  the  yet  unsettled  condition  of 
embryology  than  in  regard  to  the  JMiillerian  ducts — an  uncertainty 
which  is  explainable  when  we  remember  that  these  investigations  are 
of  a  comparatively  recent  date,  that  different  observers  sometimes  have 
worked  on  the  embryos  of  different  animals,  and  that  gradually  new 
and  improved  methods  have  been  adopted  in  the  preparation  of  the 
specimens.  As  heretofore,  we  will  chiefly  follow  Kolliker,  the  author 
of  the  most  complete  work  on  human  embryology  in  any  lan- 
guage. According  to  this  authority,  jSIiiller's  ducts  appear  shortly 
after  the  Wolffian  bodies — in  chickens  on  the  sixth  day,  in  rab- 
bits on  the  twelfth  or  the  thirteenth  day.  They  begin  as  a  ftinnel- 
shaped  invagination  from  tlie  germ-epithelium  at  the  inner  side  of  the 
upper  end  of  the  Wolffian  bodies,  on  a  level  with  the  fifth  protovertebra 
(Fig.  26).  From  this  locality  the  ]Mullerian  duct  extends  behind  the 
Wolffian  body  to  its  outer  part,  where  it  lies  close  uj:»  to  the  Wolffian 
duct,  outside  of  this  latter  duct ;  but  gradually  the  JMiillerian  duct  turns 
spirally  round  the  Wolffian  duct,  so  as  to  come  in  front  of  it,  then 
inside  of  it,  and  finally  behind  it.    The  lower  end  is  in  young  embryos 

*  Johannes  Miiller,  Handbueh  der  Physiologie  der  3fenschen,  Coblenz,  1834  et  seq. 


86 


THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


formed  of  a  solid  mass  of  cells,  in  which  subsequently  a  canal  appears. 
In  the  chicken  this  whole  development  is  finished  in  the  course  of  two 
days,  when  the  duct  opens  into  the  cloaca.  In  the  rabbit  the  develop- 
ment takes  considerably  longer  time,  probably  nineteen  or  twenty  days. 
In  human  embryos  the  perforation  takes  place  in  the  seventh  week. 
This  Ls  the  origin  of  the  Miillerian  ducts  as  observed  by  Bornhaupt, 
Egli,  and  Kolliker  in  the  chick  and  the  rabbit. 

Waldeyer,  on  the  other  hand,  who  has  investigated  the  matter  in 
chickens,  pretends  that  the  duct  is  formed  from  the  germ-epithelium  as 


Fig.  26. 


u 


u 


\ 


^N 


'TIUJ 


Transverse  Section  througli  the  upper  end  of  the  Wolffian  Body  of  the  Embryo  of  a  Rahhit 
of  14  days  (enlarged  140  times)  :  ivg,  Wolffian  duct ;  ni,  connection  between  a  tubule  of  the 
Wolffian  body  with  a  Malpighian  body ;  t,  entrance  to  the  Miillerian  duet  (later  the  abdominal 
ostium  of  the  Fallopian  tube) ;  g,  g,  mesentery  of  the  Wolffian  body,  containing  a  glandular 
tubule ;  I,  I,  surface  of  the  liver ;  lib,  posterior  abdominal  wall ;  mg',  lateral  pjart  of  the 
Miillerian  duct  (Kolliker). 

a  canal  which,  at  first  open,  becomes  gradually  closed  by  the  fusion  of 
the  borders,  so  as  to  form  a  closed  tube. 

A  third  view  is  that  put  forth  by  Balfour  and  Sedgwick.  Accord- 
ing to  these  authors,  Miiller's  duct  is  at  first  a  solid  string  of  cells 
which  becomes  detached  from  the  outer  wall  of  the  Wolffian  duct. 

The  Miillerian  duct  has  a  mesentery  of  its  own,  which  is  first  attached 
to  the  AYolflfian  body.  After  the  absorption  of  that  organ  it  is  fastened 
to  the  posterior  abdominal  wall,  and  at  a  still  later  stage  we  find  it 
starting  from  the  outer  surface  of  the  mesoarium,  as  described  above 
in  speaking  of  the  ovars^. 

If  thus  the  origin  of  the  Miillerian  ducts  is  still  somewhat  uncertain, 
their  further  development  and  ultimate  fate  are  well  known.  In  the 
male   sex   they  disappear  very  soon   almost   entirely.     In  the  male 


THE   UTERUS  AND   THE   K 167X1.  87 

(Muhrvi.  of  a   ral.l.it  ..I"  twcntv-lhnr  dnvs'  jicstation  Kolliker  fouixl  no 
trace  of  tlu'iu.      In   tlic  cliicUcn   they  disappeared   likewise  eomi)letely 
atter  the  twelfth  <lay.     In  some  animals,  siieli  as  the  niminaiils  and  the 
Caniivora,  some  remnaiils  oi"  them  are  iWiind  as  vesicular  lormations  at 
the  fundus  of  the  bladder.      In  man  the  whole  central  i)art  of  them  is 
absorbed.     The  upper  end  is  left,  and  forms  the  small  vesicle  attached 
to  the  epididymis  which  is  called  Morgagni's  hydatid.     The  lower  end 
likewise  remains,  and  forms  the  vesicida  prostatica,  which  corresponds 
to  the  uterus  and  vagina.    AVhile  in  the  male  sex  only  vestiges,  without 
any  physiological  importance,  are  left  of  the  Mullerian  ducts,  in  the 
feinale'they  become  the  ducts  through  which  the  ovum  passes  from  the 
ovary,  the' receptaculura  in  which  the  fjetus  is  developed,  and  the  tube 
in  which  sexual  connection  takes  place,  and  through  which  the  off- 
spring is  brought  out  to  separate  existence. 

The  Fallopian'  Tubes. 
These  organs  are  a  development  of  that  part  of  the  Mullerian  ducts 
which  is  situated  above  the  round  ligament.  In  the  course  of  time 
it  increases  in  size ;  it  changes  direction  in  follo^^'ing  the  ovary  down, 
and  comes  to  occupv  a  position  above  and  in  front  of  the  latter  organ ; 
the  muscular  coat  and  mucous  membrane  are  developed,  and  around 
the  opening  at  the  upper  outer  end  sprouts  out  the  row  of  tongue-like 
prolongations  constituting  the  fimbriae. 

The  Uterus'^  and  the  Vagina.^ 
That  part  of  the  Mullerian  ducts  which  is  situated  below  the  inser- 
tion of  the  round  ligament  and  the  lower  ends  of  the  Wolffian  ducts 
enter  into  close  connection  and  form  a  quadrilateral  cord  with  rounded- 
off  edcres,  the  so-called  genital  cord.  (See  Fig.  27.)  Cross-cuts  through 
this  co^rd  show  that  at  the  upper  and  louver  ends  there  are  four  epithelial 
tubules,  the  Mullerian  ducts  Iving  behind  the  Wolffian  ducts;  but  in 
the  intermediate  part  the  two  Mullerian  ducts  are  seen  growing  or 
o-rown  together,  so  as  to  form  one  single  tube,  which  is  the  first  appear- 
ance of  the  uterine  cavitv.  From  pathological  specimens  Schatz  has 
inferred  that  the  fusion  begins  just  below  the  place  where  later  the 
vaginal  portion  will  be  situated.  This  fusion  of  the  Aliillerian  ducts 
takes  place  in  the  human  embrvo  at  the  end  of  the  second  month.  As  the 
whole  of  the  genital  cord  is  used  to  build  up  the  uterus  and  the  vagina, 

^  G&hriele  FaWo^io,  Obs€rvationesanatomkre,\enet.,1r,CA.  ,        ,    , 

^  Classic  Latin  name  for  the  womb,  but  in  ancient  times  comprising  the  whole  gem- 

tal  tract. 

3  Classic  Latin,  meaning  a  slieath. 


THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 


Fig.  27. 


Transverse  Section  through  the  Genital  Cord  from  the  Embryo  of  a  Cow  1}4  inches  long  (en- 
larged 14  times) :  1,  from  the  upper  end  of  the  cord  (the  ducts  have  been  cut  somewhat 
obliquely) ;  2,  somewhat  lower  down;  3  and  4,  from  the  middle  of  the  cord,  showing  incom- 
plete and  complete  fusion  of  Mtiller's  ducts ;  5,  from  the  lower  end,  showing  the  two  Miiller- 
ian  ducts  separated;  o,  anterior;  p,  posterior  side  of  the  genital  cord;  m,  Mtiller's  duct;  wg, 
Wolffian  duct  (Kolliker). 


Fig.  28. 


Fig.  29. 


the  lower  parts  of  the  Wolffian  ducts  contribute  their  share  to  the  for- 
mation of  these  organs.  In  the  third  month  the  uterus  is  still  two- 
horned  ;  that  is  to  say,  those  parts  of  the  Miillerian  ducts  which  lie  nearer 

the  round  ligaments  are  not  yet  united. 
(See  Figs.  28  and  29.)  As  just  stated, 
the  fusion  begins  in  the  middle,  while 
the  ducts  are  still  separated  above  and  be- 
low. The  upper  parts  constitute  the  horns 
of  the  uterus,  which  persist  in  many  ani- 
mals, but  in  woman  gradually  grow  to- 
gether, the  partition  between  them  becom- 
ing absorbed,  until  finally,  about  the 
middle  of  pregnancy,  the  uterus  forms 
one  sac  without  horns,  as  seen  in  Fig.  30, 
and  containing  a  single  cavity.  The  lower 
parts  later  become  fused  together,  except 
when,  by  an  arrest  of  development,  they  persist  as  two  and  form  a 
double  vagina — a  point  to  which  we  will  come  back  in  treating  of  mal- 
formations. 

The  Miillerian  ducts  open  into  the  lower  part  of  the  urachus — i.  e. 
that  part  of  the  allantois  which  is  comprised  in  the  body  of  the  embryo 
and  forms  the  bladder  (Fig.  31).  This  lower  part-,  from  the  openings 
of  the  Wolffian  and  Miillerian  ducts  downward,  is  called  the  sinus  uro- 
genifalis  (Fig.  2,  p.  69).  Originally,  it  opens  into  the  cloaca,  a  com- 
mon vault,  in  which  end  the  urogenital  system  and  the  intestine  (Fig. 
31),  and  which  communicates  with  the  surface  through  the  cloacal 
opening  formed  by  an  invagination   from  the  epiblast  and  thinning 


Ovaries,  Tubes,  and  Uterus  from  a 
Human  Foetus  from  the  tenth 
week,  26  mm.  long  (Fig.  28  natural 
size ;  Fig.  29,  enlarged  four  times) : 
a,  the  round  ligament ;  h,  rectum 
(Meyer). 


THE   UTERUS  AM)   THE   VAGLYA. 


89 


of"  tlio  tissue  intervening  between  it  and  the  gut.     TliLs  perforation 
takes  place  in  the  human  embno  in  the  fourth  week.     In  the  course 

Fig.  30. 


Abdominal  and  Pelvic  Viscera  of  a  Female  Embryo  of  five  months  (length,  from  vertex  to  sole, 
19  centimeters— natural  size) :  t,  tube ;  r,  round  ligament ;  v,  bladder ;  «,  umbilical  artery ; 
ur,  urachus ;  c,  cfecum ;  pa,  vermiform  appendix  (KoUiker). 

of  the  sixth  and  seventh  vreeks  the  common  orifice  is  seen  to  become 
divided  into  two  parts — ^viz.  the  longer  slit  of  the  genito-urinary 
aperture  anteriorly,  and  the  narroAver  and  more  rounded  anal  open- 
ing posteriorly.  This  separation 
of  the  single  cloacal  opening  into 
two  is  probably  mainly  effected 
by  the  groAvth  of  ti.ssue  from  the 


Fig.  31. 


Fig.  32. 


I'ti 


sides  of  the  cloaca  and  downward 
from  the  point  where  the  rectum 
and  the  urachus  unite.  By  the 
formation  of  this  septum  the  sinus 
urogenitalis  is  separated  from  the 
rectum  (Fig.  32).  This  partition 
unites  with  the  posterior  end  of 
the  genital  folds  (see  Fig.  34),  and  thus  the  separation  between  the 
genito-urinary  and  the  anal  openings  is  completed  by  "the  formation  of 
the  perineum,  which  takes  place  in  the  tenth  week. 


Fig.  01.— c/,  cloaca;  all,  allantois;  m,  Miiller's 
duct;  r,  rectum  'Schroeder). 

Fig.  32. — sti,  sinus  urogenitalis ;  r,  rectum,  sepa- 
rated by  the  perineum ;  v,  vagina,  lower  part 
of  Miiller's  duct;  b,  bladder;  u,  urethra 
(Schroeder). 


90  THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 

The  sinus  urogenitalis  lags  behind  in  growth,  while  the  urethra  is 
being  formed  as  a  distinct  part,  different  from  the  bladder,  with  which 
it  hitherto  has  been  blended  into  one  organ,  the  urachus,  and  the  uterus 
and  vagina  are  being  developed  from  the  lower  part  of  the  Milllerian 
ducts.  (See  Fig.  33,  2.)  Actual  measurements  at  different  stages  of  devel- 
opment prove  that  the  sinus  urogenitalis  increases  in  size,  so  that  its 
apparent  diminution  is  only  due  to  the  comparatively  greater  devel- 
opment of  the  surrounding  parts.     In  consequence  of  the  considerable 


Fig.  33. 


LL  C/.' 

Sinus  Urogenitalis  and  its  Appendages  from  Human  Embryos  (in  life-size)  :  1,  from  a  three 
months'  fcetus ;  2,  from  a  four  months' ;  3,  from  a  sixth  months' ;  b,  bladder ;  h,  urethra ;  iig, 
sinus  urogenitalis;  g,  genital  canal,  common  rudiment  of  vagina  and  uterus;  s,  vagina; 
M,  uterus  (Kolliker). 

growth  of  the  vagina  the  sinus  urogenitalis,  which  at  an  earlier  stage 
appeared  to  be  the  continuation  of  the  bladder,  becomes  the  direct  con- 
tinuation of  the  vagina  and  forms  the  vestibule. 

At  first  the  uterus  and  the  vagina  form  only  one  organ,  without  any 
line  of  demarkation  between  the  two,  as  seen  in  Fig.  33, 1  and  2,  repre- 
senting embryos  of  the  third  and  the  fourth  month.  In  the  fifth,  and 
still  more  distinctly  in  the  sixth  month,  the  uterus  becomes  separated 
from  the  vagina  by  the  formation  of  a  ring  protruding  from  the  inner 
surface  at  the  level  of  the  future  external  os  (see  Fig.  33,  3) ;  which 
ring,  by  further  development  during  the  remaining  months  of  preg- 
nancy, becomes  the  vaginal  portion. 

In  the  fifth  month  the  uterine  wall  is  scarcely  thicker  than  that  of 
the  vao;ina,  but  from  the  sixth  month  it  increases  considerablv  in 
thickness.  Transverse  folds  appear  in  the  fifth  month,  designating 
the  cervix. 

In  the  newborn  child  the  cervix  constitutes  about  two-thirds  of  the 
whole  length  of  the  organ,  and  its  walls  are  much  thicker  than  those 
of  the  body.  In  a  specimen  lying  before  me  the  exact  outer  measures 
are — cervix,  2.2  centimeters;  body,  1.0;  wall  of  cervix,  0.3.  On 
the  outer  surface  there  is  no  distinct  line  of  demarkation  between  the 
cervix  and  the  body.  The  lower  part  forms  a  cone  the  base  of  which 
points  down  toward  the  vagina,  and  the  shape  of  which  is  such  that  a 
cross-cut  made  perpendicularly  on  the  long  axis  almost  forms  a  circle. 
The  body,  on  the  other  hand,  has  the  shape  of  a  flattened  cone,  the  basis 


THE   UTERUS  AND   THE   VAGINA.  91 

of  which  is  turned  iipwanl  to  the  alxldiiiiiial  cuNily  ;  hut  this  triaiif^iilar 
fiat  part  cxtciids  soiiu'wiiat  lower  dcnvu  tlum  tlie  internal  line  of 
deniarkation  hetween  the  cervix  and  the  hody,  and  on  tlic  anterior  sur- 
face the  peritoneum  descends  almost  as  iar  down  below  the  internal  lino 
of  deniarl<ation  (nine  millimeters)  as  ihe  whole  len<rth  of  the  hodv.  On 
the  internal  surface  the  line  of  demarkation  is  very  sharp  on  the  anterior 
surface.  The  anterior  column,  from  which  numerous  rn^ae  ^o  off  to 
both  sides  under  acute  angles  tending  outward  and  upward,  ends 
abruptly  at  a  deep  transverse  furrow  which  separates  it  from  the  cav- 
ity of  the  body.  The  whole  anterior  surface  of  the  cavity  of  the  body, 
from  this  furrow  up  to  the  fundus,  is  occujiied  by  two  large  bundles  of 
longitudinal  furrows,  each  of  which  forms  a  lengthy,  narrow  triangle, 
touching  the  fundus  with  their  base.  A  similar  formation  is  found  on 
the  posterior  wall,  but  here  the  line  of  demarkation  between  the  trans- 
verse folds  of  the  cervix  and  the  longitudinal  folds  of  the  body  is  less 
distinct.  In  both  edges  of  the  cavity  of  the  body  is  found  a  fine  lon- 
gitudinal ridge  from  Avhich  start  to  both  sides  fine  transverse  folds  end- 
ing at  the  longitudinal  folds  on  the  anterior  and  posterior  surfaces.  They 
are  a  direct  continuation  of  the  transverse  folds  found  in  the  cervix.^ 

Later  in  life  all  these  folds  of  the  cavity  of  the  body  disappear.  In 
a  figure  in  Courty's  treatise  of  the  diseases  of  the  uterus,  representing 
the  normal  uterus  of  a  girl  of  seven  years,  the  folds  are  already  limited 
to  the  cervix.  The  fundus  in  the  newborn  forms  a  straight  line  from 
one  tube  to  the  other.  The  whole  organ  is  slightly  curved  forward, 
but  there  is  no  anteflexion ;  that  is  to  say,  the  axis  of  the  organ  does 
not  form  any  angle.  According  to  Kolliker,  some  uteri  from  the  end 
of  embryonic  life,  and  during  childhood  up  to  the  age  of  pubertv, 
present  a  slight  degree  of  anteflexion.  After  that  time  the  normal 
uterus  is  straight. 

The  mucous  membrane  of  newborn  children  has  no  true  glands,  but 
only  follicular  depressions.^  The  formation  of  glands  begins  much 
earlier  in  the  cervix  than  in  the  body.  Thus  in  the  body  of  the  uterus 
of  a  girl  of  six  or  seven  years  there  are  barely  found  at  long  intervals 
some  epithelial  invaginations  which  only  penetrate  to  a  short  distance 
into  the  stroma  of  the  mucous  membrane,  constituting  rudimentary 
glands.  At  the  same  time,  those  of  the  cervix  are  jicrfectly  developed, 
and  have  even  almost  acquired  the  size  they  obtain  in  the  adult  (De 
Sinety).  It  is  true  that  even  in  the  newborn  child  we  find  the  cervical 
canal  filled  with  a  thick  colorless  mucus,  as  in  the  adult,  but  this  is 

'  This  description  of  the  cavity  of  the  uterus  with  lonrjihicUrKtl  folds  differs  entirely 
from  the  common  one,  according  to  which  the  transverse  folds  of  the  cervix  should  be 
continued  on  the  anterior  and  posterior  wall  up  to  the  fundus  ;  but  on  the  other  hand, 
it  comes  pretty  near  to  the  description,  and  especially  the  drawiufr.  of  Hagemann, 
who  injected  the  cavity  with   a  soft   metallic  composition  or  paraffin. 

■■*  Cornil,  Journal  de  I'Anatomie,  1874,  quoted  by  Imbert. 


92  THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 

merely  a  secretion  from  the  calciform  or  cup-shaped  epithelial  cells 
found  on  the  folds  of  the  cervix.  During  the  years  elapsing  between 
the  birth  of  the  child  and  its  arrival  at  puberty  the  uterus  stays  much 
behind  the  rest  of  the  body  in  development — so  much  so  that  in  a  girl 
of  ten  or  twelve  years  it  scarcely  diifers  in  external  appearance  from 
that  of  a  newborn  child  (Puech).  But  at  the  time  of  approaching 
menstruation  the  organ  increases  much  in  size — an  increase  which  goes 
on  till  the  general  gro^vth  of  the  body  reaches  its  maximum. 

The  vagina,  after  the  diiferentiation  between  it  and  the  uterus  has 
taken  place  in  the  fifth  month,  becomes  much  wider  than  the  uterus, 
and  about  the  middle  of  utero-gestation  its  folds  make  their  appearance. 

The  hymen^  is  not,  as  stated  in  most  books,  a  mere  fold  of  the 
mucous  membrane  of  the  vagina,  but,  as  demonstrated  by  dissections 
made  by  Budin,  the  whole  lower  end  of  this  canal  dipping  into  the 
vestibule.  It  is  only  a  further  development  of  the  ring-shaped  swell- 
ing with  which  the  Miillerian  ducts  are  surrounded  where  they  open 
into  the  sinus  urogenitalis.  This  development  does  not  begin  before 
the  nineteenth  week.  As  a  rule,  a  larger  part  of  the  posterior  wall 
protrudes  than  of  the  anterior.  The  internal  or  upper  surface  shows  a 
continuation  of  the  vaginal  columns  and  folds.  The  vagina  in  young 
individuals  has  the  shape  of  the  finger  of  a  glove,  with  a  small  round 
opening  or  lengthy  slit  at  the  end,  which  is  the  true  entrance  of  the 


The  Vulva.'' 

As  stated  above,  at  an  early  stage  of  embryonic  development  the 
intestine  and  the  bladder  open  into  a  common  space  called  the  cloaca, 
which  from  the  fourth  week  communicates  with  the  outer  surface  by 
means  of  an  aperture  called  the  primitive  anal  or  cloaca!  opening.  In 
front  of  this  opening  there  aj)pears  in  the  sixth  week  a  protuberance 
called  the  genital  eminence,  and  soon  thereafter  two  lateral  folds  called 
the  genital  folds  (Fig.  34).  The  genital  eminence  protrudes  more  and 
more,  and  toward  the  end  of  the  second  month  a  furrow  appears  on  its 
lower  surface  extending  to  the  outlet  of  the  cloaca,  the  so-called  geni- 
tal furrow.  From  the  fifth  to  the  tenth  week  the  cloaca  becomes  sepa- 
rated, as  described  above,  into  an  anterior  or  urogenital  part,  the  sinus 
m'ogenitalis,  and  a  posterior  or  rectal  part.  Up  to  the  tenth  week  the 
sexes  cannot  be  distinguished,  but  henceforth  the  peculiarities  of  each 
appear.     The  genital  folds  grow  to  be  the  labia  majora;^  the  edges  of 

^  Although  it  would  he  gratifying  to  the  aesthetic  and  moral  sense  to  put  this  word 
in  a  particular  relation  to  Hymen,  the  god  of  marriage,  it  simply  means  a  membrane 

'^  Classic  Latin,  but  in  ancient  times  often  comprising  the  whole  genital  canal. 
^  Latin,  labium,  lip. 


LITERATURE. 


93 


tht' liciiital  furrow  arc  develnpc'd  as  the  labia  minora;  and  the  <r<'iiital 
eniineiK-e  bccuiuos  tlio  clitoris/  round  which  is  thrown  a  fold  i'roni  the 
labia  minora  formini;  its  prcpiico.^  The  sinus  urogenitulis  rcmaias  in 
the  shaj)c  of  the  vestibule.     The  jxjsterior  part  of  the  genital   fjlds 


Fig.  34. 


Fig.  35. 


hi 


Fig.  34.— Fonnation  of  the  External  (jenitals  in  Mankind.  1,  lower  portion  of  tiie  trunk  of  an 
embryo  from  the  eighth  week,  double  .size  :  e,  gland  or  point  of  the  genital  eminence  ;  /,  gen- 
ital furrow  leading  back  to  an  aperture  which  at  this  period  communicates  with  the  rectum, 
and  consequently  is  a  cloacal  o[iening;  W,  genital  folds;  s,  caudal  extremity  of  the  body ; 
II,  umbilical  cord.  2,  from  a  Female  Embryo  about  10  weeks  old  and  1  inch  and  2  lines 
long:  a,  anus;  vg,  entrance  to  sinus  urogenitalis ;  n,  edges  of  genital  furrow  or  labia 
minora.    The  other  letters  as  in  1  (Kolliker). 

Fig.  35.— 1,  from  an  Embryo  1  inch  long,  double  size,  representing  a  stage  that  precedes  Fig.  34; 
2,  the  sex  is  not  yet  distinguishable.  2.  from  a  Male  Embryo  from  the  end  of  the  third 
month,  2  inches  and  V/,  lines  long.  Letters  as  in  Fig.  34.  In  2  the  genital  furrow  is  closed, 
forming  the  raph6  (r)  of  the  penis,  scrotum,  and  perineum  (Kolliker). 

groM'  together,  forming  the  perineum,^  which  above  unites  A\ith  tiie 
partition  which  ha.s  divided  the  cloaca  into  two  di.stinct  cavities. 


Literature  Referred  to. 

BoEHM,  C. :  "Ueber  Erkrankung  der  Gartnerschen  Giinge"  (Arch.f.  Gyndk.,  1883,  vol. 

xxi.  p.  176). 
BuDix,  P.:   "Eecherches  sur  I'llymen  et  TOuverture  du  Vagin"  [Progrts  medical, 

1879,  Nos.  35,  36,  37,  and  38). 
Chatty AU:  Anatomie  comparee  desAnirrumx  domestiques,  3d  ed.,  Paris,  1879. 
CouRTY,  A. :   Tmite  pratique  des  Maladies  de  V  Uterus  et  de  ces  Annexes,  Paris,  1866. 
DoHRN,  E.:  "Ein  Fall  von  Atresia  vaginalis"  [Archiv fixr  Gyndk.,  x.  p.  544). 
:  "Die  Gartnerschen  Kaniile  beim  "VVeibe"  {Arch. fixr  Gyndk.,  1883,  vol.  xxi. 

p.  328). 
FiscHEL,  W. :  "  Ueber  das  Vorkommen  von  Resten  des  Wolffschen  Ganges  in  der 

Vaginal  portion"  {Arch.  Jur  Gyndk.,  1884,  vol.  xxiv.  p.  119). 
FouLis:  "Cancer  of  the  Ovary"  (Edinburcjh  Med.  Journ.,  March,  1875). 
Gartner,  H.  T.  :  ''  Anatomisk  Beskrivelse  over  et  ved  nogle  Dyrearters  Uterus  un- 

dersogt  glandulost  Organ"    (Konyl.    Dansk.    Vidensk.   Sehk.   Skri/ter,   Copenhagen, 

1822). 
Geigei.,  R.  :   Ueber  Variabilitdt  in  der  Enlmckelung  der  Geschlechtsorgane,   Wiirzburg. 

1883. 
Hagemaxn  :  "Ueber  die  Form  der  Hohlung  des  Uterus"  {Arch. fixr  Gyndk.,  1873, 

vol.  V.  p.  295), 
Hedexius,  p.  :  "  Ett  fall  af  uterus  septus  nied  en  ensidig  kongenital  atresi "  (  Upsala 

Ldkareforenings  Fdrhandlingar,  1882,  vol.  xvii.  p.  530). 


^  Classic  Greek,  K?eiropic. 

^  Classic  Greek,  •zepivenv  or  ~epivaiov. 


Classic  Latin,  prccputium. 


94  THE  DEVELOPMENT  OF  THE  FEMALE  GENITALS. 

His,  Wilhelm:  Anatomie  menschlicher  Embryonen,  i.-iii.,  Leipzig,  1880-85. 
Imbert,  G.  :  Developpement  de  I'  Uterus  el  du  Vagin,  Paris,  1883. 
Jacobson,  L.  :  Die  Okenschen  Korper  oder  die  Primordicdnieren,  Kopenhagen,  1830. 
KocKS,  J. :  "  Die  Gartnerschen  Giinge  beim  Weibe "  {Archiv  fur  Gyndkologie,  1882, 

vol.  XX.  p.  485). 
KoLLiKER,  A. :  Entivickelungsgeschichte  des  Menschenund  der  hoheren  Thieve,  2te  Auflage, 

Leipzig,  1879. 

:    Ueber  die  Lage  der  iveiblichen  innern  Gesehlechtsorgane,  Bonn,  1882. 

:  "Organejunger  menschlicher  Embryonen"  [Centralbl.  fur  Gyndk.,  1884,  vol. 

viii.  p.  585). 
Meyer,  H.  :   "  Ueber  die  Entwickelung  der  menschlichen  Eierstocke"    {Arch,  filr 

Gyndk.,  1884,  vol.  xxiii.  No.  2,  p.  226). 
Milne-Edwards,  H.  :  I^egons  de  Physiologie  et  d^  Anatomie  coniparee,  vols.  viii.  and  ix., 

Paris,  1870. 
Puech,  a.  :  Des  Ovaires,  de  leurs  Anomalies,  Paris,  1873. 
QuAiN :  Elements   of  Anatomy,  edited  by  Allen   Thomson,  E.  A.  Shiifer,  and  G.  D. 

Thane,  9th  ed.,  Islew  York,  1882. 
EiEDER,  Carl:  "Ueber  die  Gartnerschen  (Wolffschen)  Kanale  beim  menschlichen 

Weibe"  {Virdiovfs  Arch.,  vol.  xcvi.  p.  100). 
Schatz,  F.  :  Vier  neue  Falle  von  unvoUkommener  Theilung  des  weiblichen  Genital- 

kanals  [Arch,  filr  Gyndk.,  1870,  vol.  i.  p.  12). 
SiNETY,  L.  De:  Manuel  pratique  de  Gynecologic,  Paris,  1879. 
Skene,  A. :  "  The  Anatomy  and  Pathology  of  Two  Important  Glands  of  the  Female 

Urethra"  (Am.  Journ.  Obst.,  1880,  vol.  xiii.  p.  265). 
Waldeyer,  W.  :  Eierstock  und  Ei,  Leipzig,  1 870. 
Wassilieff,  M.  :  "  Betreffend  die  Eudimente  der  Wolffschen  Gange  beim  Weibe  " 

{Arch.f  Gyndk.,  1884,  vol.  xxii.  p.  346). 
WiNCKEL,,  T. :  "  Die  Krankheiten  der  weiblichen  Harnrohre  und  Blase,"  Stuttgart, 

1877  {Billroth's  Handbuch  der  Frauenkr.,  vol.  iii.  part  ix.). 


THE  ANATOMY  OF  THE  FEMALE  PELVIC 

ORGANS. 

By  henry  C.  COE,  M.  D.,  31.  R.  C.  S., 

New  Yurk. 


Introductory. — lu  venturing  upon  ground  which  has  been  so  fre- 
quently trodden  the  writer  would  disclaim,  at  the  outset,  such  an  amount 
of  original  research  as  would  entitle  him  to  speak  authoritatively  upon 
any  one  of  the  many  disputed  questions  which  will  arise  in  the  course  of 
the  following  studies.  If,  then,  some  mooted  points  are  left  undecided, 
it  may  be  assumed,  without  further  exjjlanation,  that  the  writer  feels 
himself  incompetent  to  settle  them. 

It  is  intended  in  this  article  to  avoid  such  details  as  would  be  interest- 
ing only  to  the  anatomist,  and  to  present  a  brief  and  fairly  accurate 
review  of  the  pelvic  organs  as  regarded  from  the  standpoint  of  practical 
gynecology.  The  general  reader,  who  has  hitherto  been  content  to 
limit  his  knowledge  of  pelvic  anatomy  to  the  half-dozen  introductory 
pages  in  a  textbook  on  obstetrics  or  diseases  of  women,  will  be  sur- 
prised, on  looking  deeper  into  the  subject,  not  so  much  at  the  unsolved 
problems  that  confront  him  on  eveiy  side,  as  at  the  number  of  erroneous 
statements  that  have  long  received  the  sanction  of  the  highest  authorities. 

In  describing  in  detail  the  organs  of  generation  there  are  several 
orders  in  which  they  may  be  considered.  Thus  they  may  be  studied — 
1,  in  the  order  of  their  development;  2,  according  to  their  relative 
importance,  or  from  within  outward  ;  3,  from  without  inward.  The 
latter  sequence,  which  is  the  one  usually  followed,  is  the  most  natural 
one,  since  Ave  not  only  begin  with  the  study  of  simpler  structures  and 
ascend  gradually  to  those  of  greater  complexity,  but  we  observe  the 
same  order  as  in  a  systematic  examination  of  the  organs  in  the  living 
subject. 

It  is  customary  to  speak  of  the  external  and  the  internal  genitals. 
The  vagina  is  commonly  included  among  the  former,  although  not 
properly.  It  is  better  to  describe  it  by  itself  as  a  connecting-link 
between  the  external,  or  visible,  and  the  internal,  or  deep-seated, 
organs.     The  hymen  is  invariably  described  with  the  pudenda,  when, 

95 


96 


THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


as  will  be  shov^Ti  later,  it  is  strictly  a  part  of  the  vagina,  and  should 
be  considered  with  that  canal. 


THE   EXTERNAL    GENITALS. 

Synonyms. — ^^^ulva^ ;  Led.,  pudenda,  cunnus  ;  Fr.,  vulve,  parties 
genitales  externes  ;  Ger.,  Schamritze,  Schamtheile  ;  It,  vulva,  pudende ; 
8p.,  vulva,  pudendum. 

Defixitiox. — Under  this  term  is  included  that  portion  of  the  genital 
tract  which  is  visible  externally.^ 

It  should  be  added  that  this  definition  implies  that  the  subject  is 
placed  in  the  recumbent  posture,  with  the  thighs  abducted  and  the  labia 
majora  separated.     In  the  nude  erect  female  the  mons  Veneris  alone  Ls 

Fig.  36. 


The  External  Genitals,  as  seen  in  mesial  section  (Henle) :  a,  anus ;  h,  perineal  body  ;  c,  vagina ; 
d,  urethra ;  e,  lahium  minus ;  /,  clitoris ;  g,  fossa  naTicularis,  in  front  of  which  is  the  hymen. 

visible  (Fig.  36).  The  external  genitals  include  the  greater  and  lesser 
labia  and  the  clitoris,  with  the  jDarts  immediately  adjacent  to  them. 
The  meatus  urinariiis  belongs  to  the  urinaiy  tract,  with  which  it  will 
be  described.  Certain  accessory  structures,  such  as  the  bulbs  of  the 
vagina  and  the  glands  of  Bartholin,  may  be  regarded  as  common  to 
both  the  \Tilva  and  vagina,  while  the  pad  of  fat  over  the  s}Tnphysis 
pubis,  kno^m  as  the  mons  Veneris,  has  no  ftmction  whatever  in  connec- 
tion with  generation,^  but  will  be  mentioned  first  on  account  of  its 
architectural  prominence. 

^  "  Le  vulve  est  1' ensemble  des  parties  genitales  externes  de  la  femme  ;"  so  Quain's 
Anatoray,  last  ed.  :  "  All  the  parts  perceptible  externally." 

^The  term  "vulva"  is  not  sufficiently  exact,  since  it  has  been  applied  by  some 
writers  to  the  rima  pudendi.  by  others  to  all  the  parts  surrounding  the  entrance  to 
the  vagina  and  situated  anterior  to  the  hym.en  or  caruncles.  Etymologically,  the 
vulva  fvalvula)  includes  the  greater  labia  only;  and  this  was  its  original  meaning, 
according  to  ancient  writers. 

^  Comp.  Tarnier,  Charpentier,  and  Tillaus. 


Moys  \'j:\Erj.s. 


97 


MoNS  Veneris. 

Synonyms. — "  Mount  ot"  love ;"  Fr.,  niont  de  Venus,  penil,  emi- 
nence .sus-j)ubienne ;  Ger.,  Sehaiuhutrel ;  It.,  monte  di  Venere ;  *S/^., 
monte  de  Venus. 

Definition. — The  nions  is  a  somewlmt  triangular  area  or  projection 

Fig.  37. 


The  External  Organs  of  Generation  (Liischka) :  1,  1,  labia  majora ;  2,  glans  clitoridis ;  3,  the 
nymphse;  4,  pra?putiuni  clitoridis;  5,  frseniilum  clitoridis;  C,  frenulum  nympharum;  6, 
hymen;  8,  orifice  of  the  glands  of  Duverney;  9,  tuberculum  vaginae,  10,  meatus  urethrte. 

situated  in  front  of  the  symphysis  pubis.     It  is  covered  with  a  thick 
gro^\i:h  of  coarse  hair. 

The  triangular  area  mentioned  is  continuous  at  its  apex  with  the 
upper  extremities  of  the  labia  majora,  while  its  base  is  defined  by  a 
groove  at  the  lower  limit  of  the  hypogastrium,  which  is  more  or  less 
shaqjly  defined  according  to  the  amount  of  adipose  tissue  in  the  ab- 
dominal wall.  Ijaterally,  the  elevation'  melts  away  gradually  toward 
the  ino;uinal  folds,  which  form  its  extreme  lateral  boundaries.  The 
mans  cannot  be  regarded  as  in  any  sense  an  independent  structure, 
since  it  is  merely  an  imperfectly  circumscribed  collection  of  fat,  sup- 
ported by  connective  tissue,  varying  in  prominence  in  diiferent  subjects. 
The  inteofument  over  this  region  is  thicker  than  that  coveriuo;  the  rest 
of  the  abdomen,  while  the  hair  is  coarser  and  more  crisp  than  that 
found  elsewhere  in  the  body,  and  has  a  decided  tendency  to  curl.  Its 
color  will  be  found  to  correspond  quite  closely  with  that  which  is  nat- 
ural to  the  peculiar  type  of  individual  in  which  it  is  observed,  but  it  is 

Vol.  I.— 7 


98  THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

frequently  several  shades  darker  than  the  hair  of  the  head,  especially 
in  brunettes.  Appearing  at  puberty,  this  hair  reaches  a  certain  stage  of 
development,  at  which  it  persists  through  life.  It  is  rather  late  in  under- 
going the  senile  change.  It  may  be  stated  as  a  curious,  rather  than  an 
important,  fact  that  the  upper  limit  of  the  hairy  growth  on  the  external 
genitals  of  the  female  is  rather  sharply  defined  by  the  groove  before 
mentioned.  It  is  rare  to  find  a  line  of  hair  following  the  course  of  the 
linea  alba  as  high  as  the  umbilicus,  a  distribution  commonly  observed 
in  the  male.  Among  five  or  six  hundred  women  in  the  lying-in  wards 
of  the  Vienna  General  Hospital,  whose  abdomens  the  writer  inspected 
with  the  view  of  collecting  data  bearing  on  this  point,  not  over  half  a 
dozen  presented  the  hirsute  development  described,  and  these  were  sub- 
jects of  a  decidedly  masculine  type. 

Anatomy. — a.  Gross. — This  projection,  as  before  stated,  is  essen- 
tially a  cushion  of  adipose  tissue  traversed  by  interlacing  fibrous  and 
elastic  bands,  and  covered  by  the  skin  and  superficial  fasciae  which  are 
common  to  the  abdominal  wall.  The  skin  is  thick  and  has  an  oily 
feel,  the  latter  peculiarity  being  due  to  the  presence  in  it  of  numerous 
sebaceous  glands.  On  removing  the  integument  a  delicate  layer  of 
fascia  is  seen,  which  is  continuous  Avith  the  superficial  fascise  of  both 
the  abdomen  and  thighs.  This  layer  is  separated  with  difficulty,  since 
it  is  traversed  by  elastic  fibres  which  come  from  the  subjacent  tissue, 
where  they  form  a  close  network.  Certain  bundles  of  these  fibres  have 
a  definite  direction,  and  have  been  differentiated  by  Broca  in  his  descrip- 
tion of  the  sac  dartdique  ("pudendal  sac"  of  Savage^).  Thus,  some 
extend  laterally  as  far  as  the  borders  of  the  external  inguinal  rings ; 
another  set  enter  the  suspensory  ligament  of  the  clitoris,  and  others 
blend  with  the  elastic  tissue  of  the  labia  majora.  The  terminal  fibrils 
of  the  round  ligaments  may  be  traced  by  careful  dissection  into  the 
midst  of  the  fibro-lipomatous  tissue  of  the  mons.  As  will  be  inferred 
from  the  above  description,  the  fat  composing  the  mons  is  arranged 
in  the  form  of  lobules,  separated  by  fibrous  trabeculge,  and  it  does  not 
appear  as  a  diffuse  mass. 

B.  Minute. — The  microscopic  anatomy  of  the  suprapubic  region  may 
be  dismissed  in  a  few  words,  since  it  is  identical  with  that  of  any  other 
portion  of  the  skin,  plus  an  extra  amount  of  adipose.  Hair-bulbs, 
sebaceous,  and  sweat-glands  will  be  seen  in  a  cross-section ;  the  exist- 
ence of  the  latter  structures  has  been  questioned,  though  without  suf- 
ficient reason. 

Labia  Majora. 
Synonyms. — Greater,  or  external  labia,  lips  of  the  vulva;  Lat,  labia 
externa,  seu  cunni,  sen  pudendi,  alaj  majores,  etc. ;  Fr.,  grandes  Ifevres, 

^  Anatomy  of  Female  Pelvic  Organs. 


LABIA    MAJOR  A.  99 

l^vres  di'  la  \iilvi' ;   Ger.,  grosse  SclKuiilippcii  ;    //.,  ^raiidi  lal)l)ra;  -S^;., 
lal)i()s  luavdi'is. 

Definition. —  riic  labia  niajui-u  are  two  cutaneous  folds  which  begin 
at  the  lower  part  of  the  moas  Veneris,  extend  downward  and  hack- 
ward  on  either  side  of  the  vulvar  cleft,  and  terminate  bv  blendin<r  with 
the  integument  of  the  perineum.  Luschka'  ha.s  shown  that  there  is  no 
well-marked  line  of  separation  between  the  opposite  labia,  and  hence 
that  the  expressions  "anterior"  and  "posterior"  commissures,  so  far  as 
they  convey  the  idea  of  connecting  bands,  are  incorrect.^  By  the  anterior 
commissure  we  understand  simply  a  median  projection  situated  from 
one  to  one  and  a  half  centimeters  above  the  clitoris;  it  represents  the 
point  of  fusion  of  the  labia  ^vitl^  the  mons  Veneris,  and  forms  the 
anterior  or  npper  extremity  of  the  rima.  The  posterior  commissure  is 
still  less  distinct,  and  only  appears  as  a  band  when  the  labia  are  widely 
separated.  It  is  a  region,  rather  than  a  well-defined  brklge  of  shin;  it 
is  not  possible  to  identify  the  exact  point  at  which  either  labium  ends 
and  the  perineum  begins.  The  prevailing  inaccuracy  in  the  description 
of  the  posterior  commissure  has  led  to  a  similar  looseness  of  expression 
with  regard  to  the  antero-posterior  extent  of  the  perineum,  which  is 
commonly  represented  as  stretching  from  the  anus  to  the  posterior 
commissure,  instead  of  to  the  lower  edge  of  the  vulvar  orifice.^ 

Gross  Appearance, — The  cross-section  of  a  labium  is  somewhat  tri- 
angular in  shape,  so  that  we  may  regard  each  labium  as  possessing 
three  sides — a  base,  which  rests  upon  (but  is  not  attached  to)  the 
ramus  of  the  pubes,  and  two  surfaces,  an  external  and  an  internal. 
The  external  surface  is  convex,  rugose,  and  bears  a  resemblance  to  the 
scrotum,  of  which  it  is  considered  the  analogue.  The  integument  is 
similar  to  that  covering  the  mons,  and  has  a  growth  of  hair  continuous 
with  that  of  the  pubic  eminence,  while  its  sebaceous  glands  are  so  large 
that  their  openings  are  visible  to  the  naked  eye.  This  surface  is  limited 
externally  by  the  genito-crural  fold. 

The  inner  surfaces  of  well-rounded  labia,  especiallv  in  the  virgin,  are 
always  in  contact,  except  Avhen"  the  thighs  are  strongly  abducted.  They 
are  normally  smooth,  soft,  and  of  a  reddish  color,  offering  a  decided 
contrast  to  the  outer  surfaces.  Scattered  hairs  of  a  fine,  downy  cha- 
racter are  apparent  on  close  inspection. 

The  labia  are  subject  to  variations  both  in  size  and  in  degree  of 
approximation.  In  young,  well-developed  subjects  they  are  firm, 
plump,  and  are  so  closely  in  contact  as  to  entirely  conceal  the  parts 

^  Anatomie  des  menschlichen  Beckens,  p.  407. 

^  Equally  questionable  is  the  statement  of  Hart  and  Barbour,  that  "they  form  by 
their  junction — the  anterior  commissure — the  structure  known  as  the  mons  Veneris'' 
{Gyinecolorjy,  p.  46). 

*  Comp.  Savage's  definition  of  the  perineal  body,  Female  Pelvic  Orrjans,  pi.  i.,  text. 


100        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

behind  them  (vulva  connivens).  With  the  disappearance  of  their 
adipose  tissue,  a  change  which  occurs  normally  in  old  age,  they  become 
flabby  and  pendulous  and  no  longer  cover  the  nymphse.  The  appear- 
ance presented  by  such  gaping  labia,  as  observed  with  the  subject  in  the 
dorsal  position,  was  designated  by  the  older  anatomists  as  the  vulva 
hians.  It  should  be  added  that  the  vulvar  cleft  is  equally  exposed  in 
the  fcetus,  but  the  condition  here  is  to  be  ascribed  to  the  incomplete 
development  of  the  greater  labia. 

Anatomy. — a.  Gh^oss. — The  structure  of  the  labia  is  similar  to  that 
of  the  mons,  so  far  as  regards  their  integument,  adipose,  and  elastic 
tissue ;  but  the  latter  assumes  more  importance  here,  and  deserves  our 
careful  consideration.  A  layer  of  fat,  of  variable  thickness,  lies  just 
beneath  the  skin.  It  is  most  abundant  near  the  mons  and  toward  the 
external  surface,  but  fades  away  toward  the  posterior  commissure  and 
internal  surface.  The  elastic  fibres  may  be  divided  into  superficial  and 
deep  bundles,  the  former  appearing  as  a  thin  stratum  continuous  with 
the  deep  layer  of  the  superficial  perineal  fascia.  Sappey  describes  in  it 
smooth  muscular  fibres,  and  compares  it  to  the  dartos.  The  deeper 
bundles  of  elastic  tissue  were  originally  described  by  Broca,  who  dis- 
tinguished four  main  groups,  one  of  which,  he  says,  comes  from  the 
mons,  and  others  from  the  borders  of  the  external  ring  and  from  the 
pubic  rami.  The  disposition  of  the  elastic  tissue  of  each  labium  in  the 
form  of  a  sac,  having  its  neck  at  the  external  ring  and  its  fundus  just 
above  the  posterior  commissure, .  was  described  by  the  same  author. 
This  structure,  which  practically  includes  the  entire  labium  except  the 
integument,  is,  as  Savage  admits,  rarely  defined  save  in  cases  of  labial 
hernia.  It  is  really  formed  by  the  superficial  layer  of  elastic  tissue 
(that  continuous  with  the  perineal  fascia)  which  is  attached  around  the 
margin  of  the  ring.  Within  the  sac  are  the  deeper  fibres,  forming  a 
network  in  the  midst  of  a  quantity  of  adipose  tissue,  as  in  the  mons. 
If  this  is  followed  up  to  its  junction  with  the  mons,  the  lower  terminal 
fibres  of  the  round  ligament  will  be  found.  In  the  neck  of  the  sac 
will  occasionally  be  seen  the  persistent'  process  of  peritoneum  known 
as  the  canal  of  Nuck.  The  labia  derive  their  arterial  supply  from  the 
superficial  perineal  branch  of  the  internal  pudic.  The  veins  form  rich 
plexuses  in  the  subcutaneous  tissue,  finally  communicating  with  the 
vaginal  bulbs,  and  accompany  the  arteries :  the  lymphatics  enter  the 
superficial  inguinal  glands,  following  the  course  of  the  external  pudic 
artery,  as  do  those  of  the  scrotum.  The  nerves  are  the  superficial  peri- 
neal branches  of  the  internal  pudic  and  the  inferior  branch  of  the  small 
sciatic. 

B.  Minute. — The  skin  of  the  labia  is  distinguished  by  the  unusual 
size  of  its  hair-bulbs  and  sebaceous  glands.  Sweat-glands  are  also 
present.     The  hair-follicles  gradually  disappear  toward  the  inner  sur- 


LABIA    MfXORA.  101 

face,  but  the  glands  persist.  For  a  description  of  the  })apilUe,  the  dis- 
tribution of  the  blood-vessels,  and  the  ultimate  terminations  of  the 
nerves  the  reader  is  referred  to  the  chapter  on  the  skin  in  any  work  on 
normal  histology.  There  is  nothing  peculiar  in  the  minute  anatomy  of 
the  Hbrous  and  adipose  tissue. 

It  is  difficult  to  conceive  how  any  writer  can  alhrm  of  the  labia  that 
"  the  inner  surface  is  in  all  respects  like  a  mucous  membrane,  except 
that  it  poasesses  sebaceous  glands  in  jilace  of  mucous  fjUicles."  ^ 

Labia  Minora. 

Synonyms. — Lesser  labia,  nymplue ;  LaL,  labia  pudendi  minora, 
sen  interna,  alee  minores ;  Fr.,  petites  levres,  nymphes ;  Ger.,  kleiue 
Schamlippcn  ;  It.,  piccole  labbra ;  Sp.,  pequenos  labios. 

Definition. — The  labia  minora  are  two  muco-cutaneous  folds  or 
flaps  which  are  situated  between  the  labia  majora,  from  the  inner  sur- 
faces of  which  they  appear  to  spring.  The  nymphse  are  ordinarily 
described  as  "  two  reddish  folds  of  mucous  membrane."  ^  Hart  asserts, 
confidently,  that  "  they  are  skin,  thin  and  fine,  and  not  mucous  mem- 
brane, as  often  alleged."  ^  The  writer  is  not  prepared  to  accept  this 
latter  statement  without  qualification,  at  least  with  regard  to  the  labia 
minora  in  the  virgin,  which  are  always  covered  by  the  external  parts. 
Their  outer  surfaces  may  indeed  be  regarded  as  true  skin,  but  the  inter- 
nal approach  so  closely  to  the  character  of  mucous  membrane  that  the 
difi'erence  between  the  two  is  inappreciable.  It  is  only  when  the  nym- 
phae  have  been  long  exposed  by  the  separation  of  the  labia  majora  that 
their  imier  surfaces  assume  the  appearance  of  integument.  The  writer 
suggests  the  adjective  "  muco-cutaneous  "  as  a  compromise.  The  sub- 
ject will  become  more  intelligible  after  the  reader  has  studied  the 
minute  structure  of  the  tissues. 

Gross  Appearance. — These  folds  are  usually  symmetrical,  although 
one  is  sometimes  a  little  larger  than  the  other.  They  are  of  a  rose-red 
hue  in  the  virgin,  but  may  become  of  a  dark-blue  or  slat^^  color  during 
pregnancy  or  after  they  have  been  long  exposed.  Their  general  appear- 
ance has  been  aptly  compared  to  that  of  a  cock's  comb.  Beginning 
just  below  the  anterior  commissure,  the  nymphre  appear  as  double  folds 
which  meet  above  and  below  the  clitoris,  forming  respectively  the  pre- 
puce and  fraenulum  of  the  clitoris ;  they  then  descend  on  each  side  of 
the  vestibule,  along  the  base  of  the  inner  surface  of  the  labium,  with 
whicli  they  apparently  blend  at  about  its  middle.     They  are  not  lost 

^  Lusk,  Science  and  Art  of  Midwifery,  1st  ed.  p.  3 — corrected  in  last  edition. 
^  Op.  cif.,  p.  4;  Ranney,  Topographical  Relations  of  Female  Pelvic  Organs,  p.  67. 
'  Hart  and  Barbour,  Gynecology,  p.  6 ;  also,  Hart,  in  Edinburgh  Med.  Journal  for 
Sept.,  1882. 


102        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

here,  however,  but  reappear  at  the  lower  extremity  of  the  vulva,  where 
they  are  united  by  a  thin  muco-cutaneous  commissure  known  as  the 
fourchette,  or  fraenulum  vulvae  ;  ^  in  fact,  they  are  sometimes  prolonged 
so  as  to  encircle  the  entire  orifice.  These  folds  are  entirely  concealed 
in  the  virgin,  being  only  exposed  when  the  external  labia  are  widely 
separated.  They  are  quite  prominent  in  the  foetus,  because  of  their 
relatively  advanced  development,  and  in  the  aged  by  reason  of  the 
gaping  vulva. 

Fourchette. — This  is  a  delicate  fold  of  skin  (or  skin  and  mucous 
membrane  ?)  which  unites  the  posterior  extremities  of  the  nymphse.  It 
is  situated  in  front  of  the  posterior  commissure,  being  distant  from  the 
anus  2.7  cm.  in  nulliparae,  and  2.5  cm.  in  women  who  have  borne 
children.^  Its  persistence  in  the  latter  is  by  no  means  so  uncommon 
as  most  writers  affirm.  The  fourchette  occupies  a  different  position 
according  as  the  nymphse  are  in  contact  or  are  artificially  separated. 
Under  the  former  conditions  it  is  but  faintly  marked  as  a  loose  fold 
between  the  hymen  and  the  posterior  commissure;  but  when  the 
nymphse  are  drawn  apart  it  appears  as  a  tense  band,  separated  from 
the  posterior  border  of  the  ostium  vaginae  (or,  more  properly,  from  the 
lower  portion  of  the  hymen)  by  a  depression  which,  from  a  fancied  re- 
,  semblance,  has  been  termed  the  fossa  navicularis.  It  should  be  clearly 
understood  that  this  fossa  is  not  a  natural  depression,  but  is  produced 
artificially  when  the  fourchette  is  put  on  the  stretch  by  lateral  traction.^ 
The  subject  being  supine,  it  is  bounded  in  front  by  the  inner  surface 
of  the  fourchette,  behind  by  the  anterior  surface  of  the  hymen,  while 
its  base  rests  upon  the  perineal  body. 

The  writer  has  frequently  identified  the  line  mentioned  by  Hart  and 
Barbour,  which,  according  to  these  writers,  forms  as  sharp  a  limit 
between  skin  and  mucous  membrane  as  the  well-known  "  white  line  " 
at  the  anal  orifice.  This  line  of  separation  is  described  as  running 
along  the  bases  of  the  internal  aspects  of  the  nymphse,  and  crossing 
between  the  two  below  the  prepuce  of  the  clitoris  in  front  and  at  the 
base  of  the  outer  aspect  of  the  hymen  posteriorly. 

Anatomy. — a.  Gross. — Without  attempting  to  discuss  this  disputed 
subject  at  length,  we  shall  assume  that  the  labia  minora  consist  essen- 
tially of  delicate  skin,  which  on  their  inner  surfaces  passes  over  insen- 
sibly into  a  sort  of  transitional  tissue,  the  character  of  which  differs 

^  Luschka  was  the  first  who  called  attention  to  the  fact  that  the  fourchette  unites 
the  lesser,  and  not  the  greater,  labia  {op.  cit,  p.  403).  Hart  and  Barbour  are,  strangely 
enough,  at  variance  with  him  {op.  cit.,  p.  6). 

^Foster,  "Topographical  Anatomy  of  the  Uterus  and  its  Surroundings,"  Am.  Journ. 
Obsiet.,  vol.  xiii.,  Jan.,  1880. 

^Ranney  is  correct  in  his  criticism  of  the  statement  made  by  Hart  and  Barbour, 
that  "  when  the  fourchette  is  pulled  doivn  by  the  finger  a  boat-shaped  cavity  is  made — 
the  fossa  navicularis"  {op.  cit.,  p.  66). 


LA  HI  A    MfNORA. 


103 


in  (liffcM'ont  subjects.  While  it  may  sometimes  be  regarded  as  true  skin, 
tlie  limit  ol' which  is  dciiucd  by  tlic  line  before  described,  it  can,  on  the 
other  liand,  rarciv  be  c()iisi(hM-cd  as  true  unicous  mcndjrane,  sucli  as  tliat 
uhicli  hues  the  iiciiital  cauals.     The  writer  believes  that  it  will  even- 


The  Superficial  Veins  of  the  Perineum  (Savage) :  h,  g,  crura  clitoridis ;  C,  corpus  clitoridis ;  1, 2, 3, 
corpus  eavernosum  urethrse;  5,  superior  perineal  and  obturator  veins;  6,  veins  of  com- 
munication witli  superficial  epigastric  veins;  8,  9,  10,  pudic  vein  and  primary  branches; 
M,  urethral  meatus ;  V,  vaginal  aperture :  A.  anus;  T,  tuberosity  of  ischium  ;  0,  coccyx;  G, 
vulvo-vaginal  gland  ;  a,  anterior  border  of  gluteus  maximus  muscle ;  b,  superficial  sphincter 
ani  nauscle  ;  c,  c,  pubo-  and  obturator  coccygeus  muscle,  closing  upward  the  posterior 
perineal  space  bounded  by  the  coccyx,  0:  lower  border  of  gluteus,  a;  larger  sciatic  lig- 
ament, L;  tuberosity  of  the  ischium,  T;  superficial  muscles,  r!,  d;  and  inferior  border  of 
perineal  septum,  /;  e,  bulbo-cavernosus  muscle:  i,  anterior  aponeurosis,  and  k,  posterior 
aponeurosis,  of  perineal  septum;  {/,  erector  clitoridis  muscle;  /(,  left  crus  clitoridis. 


tually  be  shown  that  the  Edinburgh  anatomist  is  correct  in  his  state- 
ment, but  as  vet  the  evidence  is  not  whollv  conclusive.     We  are  at 


104        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

least  justified  in  affirming  tliat  the  nympli^  are  not  ''  folds  of  mucous 
membrane."  ^ 

The  subcutaneous  tissue  of  the  nymphse  is  entirely  devoid  of  that  fat 
which  forms  such  a  prominent  part  of  the  labia  majora.  It  consists 
almost  entirely  of  a  iibro-elastic  framework  supporting  a  rich  venous 
plexus,  in  the  meshes  of  which  are  bundles  of  smooth  muscular  fibres. 
It  is  questionable  if  we  are  justified  in  regarding  this,  with  Gassenbaur, 
as  a  variety  of  cavernous  tissue.  Kobelt^  excludes  the  nymphse  from 
the  class  of  erectile  structures. 

The  arterial  supply  of  the  lesser  is  derived  from  the  same  source  as 
that  of  the  greater  labia  (internal  pudic).  The  large  venous  plexuses 
not  only  empty  into  affluent  vessels  which  enter  the  pudic  vein,  but 
communicate  freely  with  the  vaginal  bulbs  and  with  the  perineal  veins,^ 
thus  forming  a  link  between  the  pelvic  and  perineal  systems.  The 
nerves  and  lymphatics  are  common  to  both  the  labia  majora  and 
minora. 

B.  Ilinute. — A  cross-section  of  one  of  the  nympliEe  presents  the  fol- 
lowing appearances :  The  free  surface  is  covered  with  several  layers  of 
stratified  epithelium,  the  lowermost  cells  containing  pigment-granules. 
Beneath  the  epithelium  is  the  connective-tissue  basis,  which  consists  of 
interlacing  fibres,  some  of  which  are  elastic.  Bundles  of  smooth  mus- 
cular fibres  will  be  recognized  by  their  large  fusiform  cells ;  the  latter 
will  be  found  in  greatest  numbers  along  the  course  of  the  vessels.  The 
fibrous  tissue  forms  numerous  papillae,  which  project  into  the  epithelial 
layer  and  are  provided  with  vascular  loops,  the  veinlets  returning  from 
which  enter  the  plexuses  before  alluded  to.  A  superficial  capillary  net- 
work immediately  below  the  epithelium  has  also  been  described.  The 
peculiar  nerve-termination  described  by  Krause  as  "end-bulbs"  are 
also  seen  in  the  papillae.  One  striking  feature  in  the  minute  anat- 
omy of  the  nymphse  is  the  presence  in  them  of  large  sebaceous  glands, 
which  open  upon  the  free  surface.  According  to  some  authorities, 
these  are  confined  to  the  outer  aspect  of  the  labium  ;*  they  are  said 
to  be  absent  at  birth.  It  is  generally  agreed  that  hairs  are  entirely 
absent  from  the  labia  minora :  this  is  rather  a  curious  fact  when  taken 

'  There  is  no  profit  in  pursuing  this  discussion  farther  here,  since  it  resolves  itself 
merely  into  an  expression  of  personal  opinion.  Most  authorities  in  histology,  it  must 
be  admitted,  describe  the  labia  minora  (when  they  describe  them  at  all)  as  genuine 
mucous  folds.  Klein  characterizes  them  somewhat  vaguely  as  "  fibrous  connective- 
tissue  mucous  membrane"   {Elements  of  Histology,  p.  270). 

^  Die  Mdnnlichen  ii.  Weiblichen  Wollust-Organe  des  Menschev. 

■''No  description  can  convey  any  idea  of  the  vascular  richness  of  these  parts  wliich 
can  compare  with  Savage's  plates  fpls.  vi.,  vii.).  The  reader  must  bear  in  mind  that 
it  is  only  in  very  successful  special  injections  that  the  venous  plexuses  can  be  traced 
continuously. 

*  Satterthwaite,  Manual  of  Histology,  chap.  xvi. 


L.miA  MisoiiA.  in.j 

in  connection  with  the  j)rosen('c'  of  the  glands,  since  the  two  are  usually 
inseparahk'.'  Tiie  latter  fiirni.sli  a  strong  argument  in  I'avor  ol"  the 
tegnnientarv  character  of  the  labia. 

As  to  the  venous  plexuses,  it  may  be  added  that,  in  spite  of  their 
free  coninuuiication  and  the  elastic  tissue  in  which  they  run,  we  can 

Fig.  39. 

C .  -^JfjXG^ 

3 

The  Venous  Plexuses  of  the  Vagina  and  Vulva,  as  seen  in  mesial  section  (Savage) :  B,  bladder, 
partially  inflated  ;  6,  ureter;  V,  vagina;  P,  section  of  puhis;  R.  rectum;  C.  clitoris;  1.  bulb; 
2,  its  urethral  venous  process;  3,  lower  efferent  veins:  4,  dorsal  vein  of  the  clitoris :  5,  urethral 
venous  plexus;  6,  commencement  of  vaginal  venous  plexus;  7,  8,  9, 10,  sciatic  and  gluteal 
veins;  11,  uterine  veins ;  12,  obturator  vein :  13,  internal  iliac  vein;  a.  pyriformis  muscle; 
5,  larger  sciatic  ligament ;  c,  puho-  and  obturato-  and  ischio-coccygeal  muscles ;  e.  suspen- 
sory' ligament  of  the  clitoris ;  F,  bulbo-vaginal  gland ;  g,  g,  g,  g,  roots  of  sacral  plexus 
of  nerves. 

hardly  regard  them  as  sufficiently  large  and  intimately  connected  with 
the  terminal  arteries  to  justify  the  application  of  the  term  "  erectile  " 
to  this  tissue.^ 

The  minute  anatomy  of  the  fourchette  is  similar  to  that  of  the 
nymphse.  Ranney^  states  confidently  that  its  inner  surface,  "since 
it  possesses  minute  hairs,  is  considered  as  properly  belonging  to  integ- 
unientar\'  structures :"  the  latter  clause  may  he  true,  although  the 
former  is  questionable. 

'  Quain's  Anatomy,  9th  ed..  vol.  ii.  p.  256. 

2  Compare  the  definition  of  "  erectile  tissue  "  in  Quain's  Anatomy,  Sth  ed.,  vol.  ii. 
p.  180. 

^  Top.  Relations  of  Female  Pelr.  Orrjan.^.  p.  65. 


106         THE  AS  ATOMY  OF  THE  FEMALE  PELVIC  ORG  ASS. 

Clitoris. 

Syxoxy^is. — Gr.,  Kh'-opi- ;  Led.,  penis  muliebris,  memlDrum 
muliebre ;  Fr.,  clitoris ;   Ger.,  Kitzler ;  It,  clitoride ;  Sp.,  clitoris. 

Definition. — A  small,  curved,  oblong  organ,  the  analogue  of  the 
penis  in  the  male,  situated  at  the  apex  of  the  vestibule  just  below  the 
anterior  commissure. 

As  ordinarily  seen,  the  clitoris  (or  rather  its  giaus)  appears  as  a  small 
pea-shaped  projection  hidden  between  the  diverging  folds  of  the  labia 
minora.  It  is  only  when  the  latter  are  widely  separated  that  the  end 
of  the  organ  is  seen.  The  reader  whose  attention  has  not  l^een  spe- 
cially directed  to  the  subject  will  be  somewhat  suri^rised  at  the  actual 
size  of  the  clitoris  in  the  living  female,  since  many  of  the  descriptions 
and  drawings  in  the  textbooks  must  have  led  him  to  suppose  that  it 
actually  resembles  a  small  penis.  Nothing  could  be  more  erroneoiLS 
than  this  notion.  The  glans  clitoridis,  which  is  the  only  portion  of  the 
organ  that  we  ever  see  normally,  except  in  dissections,  is  in  its  most 
turgid  condition  merely  a  small  projection,  rarely  larger  than  a  small 
pea,  and  more  often  smaller.  In  some  women  it  cannot  even  be  dis- 
covered without  a  search.  By  bearing  this  fact  in 
Fig.  40.  mind  the  relative  .insignificance  of  the  clitoris  when 

compared  with  the  male  organ  will  be  intelligently 
appreciated.  Of  course,  the  apparent  variations  in 
the  size  and  prominence  of  the  former  are  explained 
to  some  extent  by  the  thickness  of  the  nymphfe.  Al- 
though it  has  but  a  limited  range  of  motion,  during 
erection  it  becomes  distinctly  arched,  the  glans  pro- 
trudes sensibly,  while  the  iDody  may  be  felt  as  a  firm 
cord  curving  upward  and  backAvard  until  it  is  lost  be- 
neath the  pubic  arch. 

Gross  Appearance. — The  comj^onent  parts  of  the 
The  Venous  Plexuses  of  clitoris,  as  considered  from  before  backward,  are  the 
the  Clitoris  (Savage) :  glans,  bodv,  and  crura.  The  attached  folds  of  the 
o'nThrbiunr^n'd  ^of  nymphse,  known  as  the  prepuce  and  frtenulum,  should 
the  clitoris ;  2,  dorsal  pj-Qperlv  be  described  in  connection  \dx\\  the  glans. 

vein  of  clitoris ;  3,  ure-   -C^i-  -,  •  t      •         ^  i- 

thrai  venous  process  The  glans  clitoridis,  which  IS  the  oniv  portion 
I'ratiti'htncS;  of  the  organ  ^nsible  without  dissection,  is  a  small 
5,  pars  intermedia;  6,  mass  of  erectile  tissue  covercd  by  mucous  membrane 
ruspTnSry°^i£ment  (or  skin  ?),  which  is  partially  enveloped  by  a  sort. 
of  clitoris :  9,  section  ^f  ^^^^  formed  bv  the  upper  of  the  two  folds  into 

of rislitcrus clitoridis.  ,     ^  -,..-,     /  •  t        •  t  \     rni 

which  the  nymphse  divide  (preputmm  clitoridis).   i  lie 
lower  folds  bend  sharply  inward  to  meet  in  the  median  line  beneath  the 
glans,  to  which  they  are  attached,  forming  its  fr^nidimi  ^  (Fig.  40). 
1  Hart  and  Barbour  describe  the  fraenulum  as  if  it  was  the  same  as  the  suspensory 


CLITORIS. 


107 


If  the  ivailor  will  rcnu-nibt'r  the  difference  of  opinion  concerning  the 
true  character  of  the  tissue  covering  the  nymphae,  he  will  rightly  infer 
that  the  same  doubt  exists  as  to  whether  the  glans,  with  its  fra^nulum 
and  prepuce,  is  clothed  with  skin  or  with  mucous  membrane.^ 

The  corpus  clitoridis  is  a  firm,  cord-like  body,  seldom  exceeding  an 
inch  -  in  length  even  when  turgescent.  It  is  situated  in  the  median 
line  in  front  of  and  below  the  symphysis  pubis,  and  may  be  traced 
upward  beneath  the  prepuce,  and  then  backward  to  a  point  immediately 
under  the  anterior  edge  of  the  pubic  arch,  where  it  divides  into  the  two 
crura  (Fig.  41.)    It  is  partly  attached  and  partly  dependent,  the  limit 


Fig.  41. 


Front  View  of  Perineal  Septum,  showing  entire  clitoris  (Savage) :  1,  clitoris ;  2,  suspensory  liga- 
ment; 3,  crura  of  clitoris;  4.  subpubic  ligament:  5,  dorsal  vein  of  clitoris;  6.  perineal  sep- 
tum; 7,  superficial  transverse  muscle:  U,  urethra;  V,  rectum  and  vagina;  P,  site  of 
perineal  body. 

between  the  fixed  and  movable  portions  being  defined  by  the  point  of 
insertion  of  the  suspensory  ligament.  The  latter  is  a  small,  but  per- 
fectly distinct,  band  of  fibres  which  extends  from  the  anterior  aspect  of 

ligament  of  the  clitoris  ( Gj/no'colof/}/,  p.  4i.  Eanney  says  that  tlie  lower  folds  of  the 
nymphre  '"help  to  complete  tlie  suspensory  ligament  of  the  clitoris"  {op.  cit.,  p.  67). 
This  is  certainly  an  error.  In  Qnain's  Anatomj  (9th.  ed.,  p.  700)  we  read  :  "There  is 
a  small  suspensory  ligament  attached  to  the  upper  border,  like  tliat  of  the  penis." 
Tliis  agrees  with  Savage's  plate  (pi.  vi.  Fig.  3)  and  with  tlie  writer's  own  dissections. 

'  Lusk  (p.  3)  speaks  of  the  "cuticular  covering  of  the  glans  "—an  apparent  incon- 
sistency, as  he  considers  the  ]ire]mce  as  a  mucous  fold. 

^  Quain  says  an  inch  and  a  half. 


108         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

the  symphysis  (above  its  middle  point)  to  the  upper  border  of  the  pos- 
terior half  of  the  corpus  clitoridis.  In  front  of  its  point  of  attachment 
the  clitoris  is  somewhat  dependent,  like  the  penis,  although  its  move- 
ments are  further  restrained  by  the  frsenulum. 

The  crura  are  two  long,  fusiform  processes  of  spongy  tissue,  less  than 
half  an  inch  in  diameter,  which  arise  from  the  anterior  borders  and 
inner  surfaces  of  the  pubic  and  ischiatic  rami,  to  ^^^hich  they  are 
attached  by  firm  connective  tissue :  they  extend  upward  along  the 
anterior  edges  of  the  ascending  rami  until  they  almost  reach  the 
symphysis,  when  they  turn  forward  and  coalesce  beneath  the  arch  to 
form  the  body.  The  inner  side  of  each  crus  is  covered  by  the  slender 
erector  clitoridis  muscle  (erector  penis  or  ischio-cavernosus),  wliich  has 
its  origin  on  the  front  of  the  tuber  ischii,  and  its  insertion  by  two  sep- 
arate tendinous  expansions,^'  one  above,  where  the  crura  join  to  form 
the  clitoris — one  in  front  and  somewhat  below."  ^ 

Anatomy. — a.  Gross. — The  clitoris  consists  essentially  of  cavernous 
tissue  surrounded  by  a  firm,  fibrous  covering  (tunica  albuginea),  over 
which  is  an  extremely  sensitive  tissue.  Its  gross  resemblance  to  the 
penis,  which  is  only  partially  apparent  in  the  glans,  is  borne  out  in 
a  longitudinal  section  of  the  body,  which  shows  that  it  is  composed  of 
symmetrical  halves  (corpora  cavernosa)  separated  by  an  imperfect  or 
rudimentary  septum  pectiniforme.  These  corpora  cavernosa  are  clearly 
the  prolongations  of  the  crura,  which  they  resemble  both  in  their  gross 
and  in  their  microscopic  anatomy. 

The  spongy  character  of  the  tissue  is  apparent  even  to  the  naked  eye : 
the  trabecule  look  much  finer  than  those  of  the  male  organ.  The  crura 
resemble  unyielding  fibrous  cords,  so  that  the  presence  in  them  of  erectile 
tissue  would  never  be  susjpected  from  an  external  examination.  On  sec- 
tion this  tissue  is  found  to  occupy  the  central  portion  of  each  crus,  and 
to  disappear  gradually  toward  the  point  of  origin.  It  is  covered  by  a 
thick  fibrous  layer  of  almost  cartilaginous  firmness,  which  gives  to  the 
body  its  cord-like  feel. 

At  their  origin  the  crura  are  entirely  fibrous  (or  ligamentous  ?)  in 
their  structure  (Fig.  41). 

Vascular  Sujjpli/. — In  studying  this  we  enter  upon  the  subject  of  the 
erectile  organs  of  the  female,^  which  should  first  be  considered  in  detail, 
and  then  in  their  relations  to  one  another  and  to  the  general  circulation. 
The  clitoris  is  the  most  important  link  in  the  chain  that  may  be  said  to 

^  Savage,  op.cit,  p.  6  and  pi.  i. 

2  Ranney  (op.  cit.,  p.  98),  after  Savage,  divides  the  pelvic  structures  rather  arbitrarilj 
into  three  classes— the  "erectile,"  " erecto-turgescent,"  and  " turgescent."  The  former 
includes  the  clitoris  and  its  crura ;  the  latter  the  urethra  and  vagina ;  while  the  body 
of  the  uterus  and  the  ovarian  and  vaginal  bulbs  belong  to  the  second  class.  ^  As  this 
idea  rests  upon  physiological  rather  than  upon  anatomical  facts,  we  can  give  only 
this  passing  reference  to  it. 


CLITORIS.  109 

begin  at  the  vat«;inal  bulbs  and  to  end  at  the  ovary.  It  receives  its 
arterial  supply  from  the  two  terminal  branches  of  the  pudic,  which  run 
between  the  point  of  junction  of  the  criiia  and  the  arch  of  the  pubic 
bones,  pierce  the  suspensory  ligament,  and  follow  along  the  din'sum  of 
the  organ  on  either  side  of  the  vein.  One  of  these  vessels  supplies  the 
body  of  the  clitoris,  corresponding  to  the  artery  of  the  coqjus  cavcrno- 
suni  in  the  male ;  it  is  called  the  profunda.  The  otlier*  larger  branch 
is  the  analogue  of  the  dorsal  artery  of  the  penis,  and  divides  at  its  ter- 
mination into  twigs  ^vhich  sujjply  the  glans  and  prepuce  (dorsal  artery).' 
These  two  ai'teries  have  a  free  intercomnumication  b}'  means  of  their 
small  branches.  Their  jweuliar  ultimate  terminations  will  be  described 
Avitli  the  minute  anatomy  of  the  ])art.  The  blood  is  returned  from 
the  clitoris  by  the  dorsal  vein,  which  begins  by  the  union  of  efferent 
branches  from  the  glans,  around  the  end  of  which  is  a  small  plexus, 
and  receives  numerous  tributaries  as  it  passes  backward  along  the  dor- 
sum between  the  two  arteries  before  mentioned,  and  reaches  the  pelvis 
by  ascending  to  the  space  between  the  arch  and  the  subpubic  ligament. 
It  terminates  in  the  vesical  plexus.^  The  upper  ends  of  the  vaginal 
bulbs  are  so  intimately  related  to  the  veins  of  the  clitoris  that  Hart 
and  Barbour  regard  the  pars  intermedia  as  almost  a  portion  of  the 
organ.  "  The  glans  clitoridis,"  they  affirm  (p.  4),  "  is  not  directly 
continuous  with  the  body,  but  joins  it  through  the  pars  intermedia  of 
the  hulb."  The  writer  has  never  been  able  to  verify  this  statement.'^ 
Besides  their  connection  with  the  pars  intermedia,  the  veins  of  the 
clitoris  communicate  with  the  urethral,  perineal,  pelvic,  and,  indirectlv, 
with  the  obturator  veins,  as  will  be  readily  understood  by  a  glance  at 
Savage's  plates  (pi.  vi.).  The  difference  between  the  vas<^lar  supplv 
of  the  penis  and  clitoris  is  greater  than  appears  at  first  (sight,  that  of 
the  latter  being  both  richer  and  more  complex  in  its  relations.  The 
difference  may  be  roughly  stated  by  saying  that  the  penis  has  a  richer 
infernal,  the  clitoris  a  more  extensive  external,  supplv. 

The  clitoris  is  surrounded  by  a  plexus  of  lymphatics  which  receive 
numerous  branches  from  the  deep  tissues,  the  whole  terminating  in  the 
superficial  inguinal  glands. 

The  nerves  of  the  clitoris  are  unusually  numerous,  considering  its 
size.  "■  Small  as  this  organ  is  compared  mth  the  penis,"  says  Savage, 
*'  it  has  in  proportion  four  or  five  times  the  nervous  supply  of  the  lat- 
ter."    Numbers  of  fibres  belonging  to  the  sympathetic  system  accom- 

^  Kobelt  (op.  cif.)  mentions  several  small  unnamed  branches  which  run  to  the  cor- 
pora cavernosa. 

^  For  an  elaborate  description  of  the  venous  plexuses  of  this  region  see  Gussen- 
bauer's  paper,  "  Ueber  das  Gefass-System  der  iiusseren  Weiblichen  Genitalien,''  Siiz- 
unr/sb.  der  Wiss.,  July,  1869. 

^  Savage  refers  to  the  pars  intermedia  as  "  a  double  row  of  veins  issuing  from  a 
double  series  of  apertures  at  the  under  surface  of  the  clitoris." 


110         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

pany  the  arteries  and  enter  with  them  the  erectile  tissue.  The  pudic 
nerve,  after  giving  off  muscular  branches,  terminates  in  a  twig  of  much 
larger  relative  size  than  the  corresponding  one  in  the  penis,  which 
accompanies  the  artery  between  the  layers  of  the  deep  perineal  fascia, 
pierces  the  suspensory  ligament,  and  runs  along  the  dorsum  as  far  as 
the  glans,  where  it  terminates  in  a  network  which  has  been  aptly 
described  as  "  a  true  nervous  sheath."  It  gives  oif  several  branches  to 
the  body  and  prepuce,  and  one  of  considerable  size  to  the  interior  of 
the  organ.  There  is  a  free  communication  between  the  sympathetic 
and  spinal  nerves  of  the  clitoris. 

B.  Jlinute. — The  minute  structure  of  the  organ  resembles  so  closely 
that  of  the  penis  that  it  will  be  unnecessary  to  repeat  a  description  with 
which  the  reader  is  doubtless  somewhat  familiar.  The  glans  has  an 
external  covering  w^iich  is  similar  to  that  of  the  nymphge  as  regards 
the  presence  of  papillae,  covered  by  layers  of  stratified  epithelium  and 
containing  capillary  loops  and  nerve-terminations  (end-bulbs).  There 
are  j)resent  iii  addition  a  special  variety  of  end-bulbs  known  as  "  the 
genital  corpuscles  of  Krause,"  which  are  also  found  in  the  mucous  cov- 
ering of  the  glans  penis.  The  erectile  tissue  of  both  the  glans  and 
body  does  not  need  a  separate  description.  As  before  stated,  the  tra- 
beculse  are  more  delicate  than  in  the  penis,  and  the  tissue  is  rather  a 
collection  of  venous  plexuses  than  of  cavernous  spaces.  The  opposite 
halves  of  the  corpus  are  j)ractically  one,  since  the  septum  between  them 
offers  no  barrier  to  the  free  intercommunication  of  the  plexuses.  If  a 
number  of  cross-sections  of  the  corpus  and  crura  are  examined,  the 
fibrous  covering  (tunica  albuginea)  will  be  seen  to  increase  in  thickness 
from  before  backward  at  the  expense  of  the  spongy  tissue,  until  the 
latter  dwindles  away  at  the  origin  of  the  crura. 

Vestibule.^ 

SYisroisrYMS. — Lat,  vestibulum,  atrium  vaginae ;  F7\,  vestibule,  canal 
vulvaire  ;   Ger.,  Vorhof ;  It.  and  8p.,  vestibulo. 

Definition. — The  vestibule  is  a  triangular  area,  the  sides  of  which 
are  formed  by  the  inner  edges  of  the  nymphse,  while  its  base  corresponds 
Avith  the  upper  margin  of  the  vaginal  orifice.  Its  apex  lies  immediately 
below  the  clitoris. 

The  vestibule  is  ordinarily  included  among  the  structures  forming 
the  vulva,  although  it  is  simply  a  surface  covered  by  mucous  mem- 
brane, which  is  of  importance  only  because  of  the  structures  contained 

^  As  its  name  implies,  the  vestibule  has  been  regarded  as  the  entrance  to  the  vagina. 
Thus  Dunglison  defines  it  as  "a  smooth  cavity  between  the  perineum  and  nymphse  in 
the  female,  which  leads  to  two  passages — to  the  urethra  above  and  to  the  vagina 
below."  French  anatomists  have  termed  it  the  canal  vulvaire.  It  is  better  to  regard 
it  as  entirely  independent  of  the  vaginal  orifice. 


VESTniri.i:.  ni 

within  it.  lli'iilc  aj>[)li('s  tlu'  ikuiic  to  (lie  l:il)i:i  |ni(lcii<li  and  tlic  space 
botwtrn  tiirni. 

Grosn  Appearance. — Tho  vcstilnili'  is  covered  hy  nincons  nienibraiie, 
wliieh  presents  a  corrugated  apiK'aranee.  Tlie  color  of  this  nienibrane 
is  retlder  and  its  texture  finer  than  that  of  the  nynipliie.  The  line 
of  separation  between  sUin  (or  transitional  tissue?)  and  mucous  mem- 
brane is  not  so  well  defined  here  as  it  is  at  the  ed";e  of  the  vay-inal 
orifice.  Several  depressions  or  crvpts  (glandidie  vestibulares  minorcs) 
will  be  observed  on  the  floor  of  the  vestibule  :  most  of  these  are  ranged 
about  the  uretiiral  opening,  which  appears  as  a  small  dimple  or  pucker 
in  the  mucous  membrane  at  the  middle  of  the  base  of  the  triangle, 
three-fourths  of  an  inch  below  the  clitoris  and  about  an  inch  frcjm 
the  fourchettc.     The  meatus  will  be  described  with  the  urinary  tract. 

The  dimensions  of  the  vestibide,  as  well  as  the  appearance  of  its 
mucous  membrane,  are  quite  variable,  especially  in  multiparte.  More- 
over, the  crypts  are  sometimes  of  minute  size,  while  they  may  be  one- 
third  as  large  as  the  meatus.  They  vary  in  number ;  there  are  generally 
five  or  six. 

AxATOMY. — A.  Gross. — On  dissecting  off  the  mucous  membrane 
of  the  vestibule  an  intricate  venous  plexus  will  be  observed,  which  can 
only  be  studied  satisfactorily  by  means  of  special  injections.  When 
fully  injected  these  veins  are  seen  to  have  a  general  transverse  direc- 
tion both  above  and  below  the  urethral  orifice ;  they  constitute  the 
pars  intermedia,  and  serve  both  to  unite  the  opposite  \'^stibular  bulbs 
(hence  the  name  "  isthmus ")  and  to  establish  a  free  communication 
between  these  bodies  and  the  vessels  of  the  corpora  cavernosa  of  the 
clitoris. 

Much  confusion  has  arisen  on  account  of  the  vague  description  of  the 
bulbs  in  most  textbooks.  A  study  of  the  best  plates,  supplemented  by 
careful  dissections  of  this  region,  will  convince  the  reader  that  the 
bulbs  are  situated  not  'svithin,  but  at  the  sides  of,  the  vestibular  area, 
that  space  being  occupied  only  by  the  connecting  plexuses  above  men- 
tioned. Moreover,  the  expression  "  glandulse  vestibulares  majores,"  as 
applied  to  the  vulvo-vaginal  glands,  is  misleading,  since  it  gives  the 
impression  that  these  structures  are  related  to  the  vestibule,  which  is 
incori'ect. 

B.  Minute. — Microscopically,  the  vestibule  presents  nothing  of  special 
interest :  as  viewed  in  a  cross-section  its  superficial  covering  consists  of 
several  layers  of  pavement  epithelium.  The  mucous  glands,  the  diam- 
eters of  which  vary  from  0.5  to  2.5  mm.,  are  of  the  compound  racemose 
type,  consisting  of  numerous  acini  which  open  into  branching  ducts ; 
these  latter  terminate  in  single  short  ducts  which  open  on  the  free  sur- 
face by  large  orifices.  The  acini  are  lined  with  a  single  layer  of  cohmi- 
nar  epithelium,  which  is  continued  into  the  ducts  as  far  as  their  orifices, 


112        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

where  it  passes  gradually  into  the  pavement  variety.  Beneath  the 
mucous  membrane  is  a  rich  network  of  fine  capillaries,  which  may 
be  traced  into  papillse  to  form  loops,  in  the  manner  already  mentioned. 
Sebaceous  glands  are  entirely  absent.  There  are  no  special  features 
about  the  nerve-supply  of  this  region ;  it  is  not  so  rich  as  that  of  the 
surrounding  parts.  Beneath  the  mucous  layer  is  a  layer  of  connective 
tissue  in  which  is  the  venous  plexus  constituting  the  pars  intermedia. 
The  veins  are  immediately  surrounded  by  a  layer  of  fibro-muscular 
tissue,  so  that  this  region  may  be  included  among  the  turgescent  bodies 
in  Savage's  classification. 

Before  describing  the  vagina  it  is  necessary  to  refer  to  two  pairs  of 
bodies  which  are  in  immediate  relation  with  the  vulvo-vaginal  orifice, 
although,  as  has  been  stated,  they  are  more  commonly  described  in  con- 
nection with  the  vestibule.  These  are  the  vaginal  bulbs  and  the  vulvo- 
vaginal glands.  These  structures  are  quite  dissimilar  in  their  character 
and  functions,  since  the  former  are  essentially  erectile  masses  belonging 
to  the  chain  which  terminates  with  the  bulbs  of  the  ovaries,  while  the 
latter  are  simply  mucous  glands  of  unusual  size. 

The  bulbs  of  the  vagina  (bulbi  vestibuli  vaginse,  bulbs  of  the  vesti- 
bule) are  two  oval  masses  of  veins  situated  on  either  side  of  the  base  of 
the  vestibule  and  the  upper  two-thirds  of  the  vulvo-vaginal  outlet. 
They  have  been  described  as  ''  leech-shaped  masses  of  reticulated 
veins."  They  are  somewhat  conical  in  shape,  their  bases,  which  are 
rounded  and  measure  half  an  inch  in  diameter,  being  opposite  the 
lower  third  of  the  ostium,  while  their  apices  (not  sharply  defined) 
extend  as  high  as  the  level  of  the  meatus  urinarius,  where  they  are 
prolonged  by  the  pars  intermedia  as  high  as  the  root  of  the  clitoris.^ 
Their  length  is  about  an  inch  and  a  half  It  should  be  stated,  in 
explanation,  that  this  description  of  the  bulbs  applies  to  these  bodies 
when  distended  by  injection.  The  reader  who  attempts  to  dissect 
them  out  in  their  collapsed  state  will  be  greatly  disappointed  at  the 
discrepancy  that  will  exist  between  his  dissections  and  the  classical  plate 
of  Kobelt.^  Hence  Hart  and  Barbour  (p.  10)  describe  them  as  "small 
masses  of  erectile  tissue  about  the  size  of  a  bean."  When  distended 
they  fill  the  spaces  between  the  vestibule  and  edges  of  the  ostium  and 
the  pubic  arch.  Their  relations  have  already  been  partly  described. 
They  surround  the  ostium  vaginse,  their  inner  surfaces  being  just 
beneath  the  mucous  membrane  of  the  vagina,  while  posteriorly  they 
are  in  contact  with  the  anterior  layer  of  the  triangular  ligament.    They 

1  Quain  {Anatomy,  last  ed.)  makes  the  doubtful  statement  that  "their  upper  pointed 
extremities  are  attached  to  the  crura  of  the  clitoris." 

■^  It  is  difficult  to  escape  the  impression  that  Kobelt's  drawing  is  exaggerated,  since 
he  figures  the  lower  ends  of  the  bulbs  as  actually  on  a  level  with  the  anterior  edge 
of  the  perineum.  Savage's  plate  (pi.  vi.)  corresponds  more  nearly  with  the  results  of 
most  dissections. 


VESTIBULE.  113 

arc  j)artially  covorod  on  llicir  anterior  and  ontor  asjiocts  by  the  hullio- 
oavornosi  niiii^cles.  lichind  their  lower  ends  are  the  vulvo-vajrinal 
ghinds. 

Thi'  hnlhs,  wliieh  are  retiarded  as  tlie  analoirues  of  the  bidl)  of  the 
urethra  in  the  male,  consist  anatomically  of  complicated  venous  plex- 
uses enclosed  in  tibrons  sheaths.  The  expression  "masses  of  erectile 
tissue"  ^  freijnently  applied  to  them  is  not  strictly  correct.  Savaj^e  is 
more  exact  in  referring-  these  bodies  to  the  class  of  erccto-turgescent 
structures.  The  chief  feature  about  their  gross  anatomy  is  the  free 
comnnniication  of  their  veins  Avitli  neighboring  ])lexuses.  Xot  only 
are  they  intimately  connected  with  each  other  by  the  veins  of  the  isth- 
mus, and  with  the  vessels  of  the  clitoris  by  the  pars  intermedia,  but 
they  comnuuiicate  freely  Avith  the  veins  of  the  labia,  perineum,  and 
vagina,  and  even  with  the  plexuses  which  unite  to  form  the  obturator 
vein,  as  well  as  with  the  epigastric  veins.  Their  arterial  supply  is 
derived  from  branches  of  the  internal  pndic.  Their  nervous  twigs 
are  largely  derived  from  the  sympathetic  system,  the  nerves  accom- 
panying the  arteries. 

A  microscopical  section  of  a  bulb  will  not  add  much  to  the  infor- 
mation gained  by  a  gross  inspection.  Externally  there  is  a  layer 
of  firm  connective  tissue,  beneath  which  is  a  dense  mass  of  veins 
and  tortuous  arteries  surrounded  by  fibro-muscular  tissue,  the  his- 
tological structure  being  analogous  to  that  of  the  erectile  tissue  of 
the  clitoris,  except  that  the  trabeculse  are  largely  replaced  by  actual 
veins. 

The  vulvo-vao;inal  elands  (glands  of  Bartholin  or  Duvernev)  are 
small  oval  bodies,  of  a  reddish-yellow  color,  varying  in  size  from  a 
bean  to  an  almond,  situated  on  each  side  of  the  vaginal  orifice  near 
the  lower  extremities  of  the  bulbs.  They  lie,  as  a  rule,  behind  the 
anterior  layer  of  the  triangular  ligament^  (like  CoAvper's  glands  in 
the  male,  to  which  they  are  analogous),  and  hence  behind  the  rounded 
ends  of  the  bulbs.  They  are  situated  beneath  the  superficial  perineal 
fascia,  in  front  of  the  transversus  perinei  muscles,  and  between  the 
lower  edo;e  of  the  orificium  vaginse  and  the  erectores  clitoridis  mus- 
cles.  The  glands  vary  in  size  in  diiferent  subjects :  they  are  largest 
in  young  women,  while  in  the  aged  they  become  atrophied,  and  may 
even  disappear.  Huguier  thought  that  he  succeeded  in  establishing 
some  relation  between  the  size  of  a  gland  and  that  of  the  ovary  on 
the  same  side.  During;  sexual  excitement  these  bodies  share  in  the 
general  tm^gescence  of  the  vulvo-vaginal  region.     Each  gland  has  a 

'  Eanney,  Annals  of  Anatomy  and  Surgery,  April,  1883,  p.  4. 

^Eannev,  N.  Y.  Medical  Journal,  July,  1882;  a\s>o  Annals  of  Anatomy  and  Surgery, 
April,  1883.  He  admits  that  they  may  lie  either  in  front  of  or  behind  the  posterior 
layer. 

Vol.  I.— 8 


114        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

duct,  from  a  half  to  three-quarters  of  an  inch  in  length,  and  less  than 
one-fifth  of  an  inch  in  diameter,  which  runs  along  the  inner  margin 
of  the  rounded  extremity  of  the  bulb,  and  opens  into  the  fossa  navicu- 
laris  on  the  inner  surface  of  the  nymphse,  just  in  front  of  the  base  of 
the  hymen. 

Microscopically,  the  vulvo-vaginal  glands  belong  to  the  compound 
racemose  variety,  their  acini,  secondary,  and  discharging  ducts  being 
lined  by  columnar  ejDithelium.  Their  secretion  is  a  yellowish,  tena- 
cious mucus,  Avhich  acts  simply  as  a  lubricant  to  the  parts ;  its  expul- 
sion is  favored  by  the  reflex  contraction  of  the  surrounding  perineal 
muscles, 

Peactical  Deductions. — Bearing  in  mind  the  tegumentary  cha- 
racter of  the  external  genitals,  the  reader  will  naturally  infer  that  they 
are  subject  to  many  of  the  same  affections  as  the  skin  in  other  portions 
of  the  body,  and  that  these  are  to  be  referred  to  essentially  the  same 
causes.  It  is  hardly  necessary  to  refer  to  the  risk  incurred  by  the 
physician  wliile  practising  the  vaginal  touch  in  infected  females  :  there 
is  no  more  dangerous — because  unsuspected — source  of  infection. 

The  comparative  frequency  of  hypertrophy  of  the  external  genitals  is 
readily  explained  by  reference  to  their  structure :  thus,  an  excessive 
development  of  adipose  may  result  in  enormous  enlargement  of  the 
mons  or  labia,  so  as  to  interfere  with  locomotion  or  sexual  intercourse, 
while  hypertrophy  of  the  skin  and  fibrous  tissue  may  be  still  more 
marked,  as  in  elephantiasis.  The  contractile  character  of  the  tissues 
not  only  renders  healing  difficult  after  extensive  loss  of  substance  from 
wounds,  sloughing,  the  ravages  of  rodent  ulcer,  etc.,  but  leads  to  the 
formation  of  large,  ugly  cicatrices.  Hence  the  danger  (aside  from  that 
of  hemorrhage)  which  follows  the  excision  of  large  tumors. 

Inflammatory  affections  of  the  vulva  are  seldom  confined  strictly  to 
this  region,  but  involve  the  lower  end  of  the  vagina,  and  frequently  the 
urethra,  because  of  the  direct  continuity  of  the  mucous  membrane ;  con- 
versely, inflammation  of  the  vagina,  especially  when  of  a  specific  cha- 
racter, generally  extends  to  the  nymphse.  The  extreme  pain  and  hyper- 
sesthesia  which  attend  eruptions  and  inflammation  of  these  parts,  fre- 
quently out  of  proportion  to  the  local  trouble,  afford  a  striking  clinical 
proof  of  their  rich  nerve-supply,  while  the  reflex  symptoms  that  some- 
times result  from  an  insignificant  eruption  would  be  inexplicable  did  we 
not  recall  the  intimate  relation  between  the  cerebro-spinal  and  sympa- 
thetic nerves,  which  is  by  no  means  confined  to  the  internal  genitals. 
Burning  and  itching  sensations  about  the  vulva  may  thus  cause  a  con- 
siderable amount  of  general  disturbance.  A  familiar  illustration  of 
this  is  offered  in  the  sensitive  red  patches  which  are  seen  on  the  inner 
surfaces  of  the  nymi^hse  in  women  who  have  passed  the  climacteric, 
especially  in  connection  with  urethral  caruncle. 


VESTIBULE.  115 

TIk'  extensive  aiiasloim iscs  of  the  piuk'ndul  veins  with  the  ])elvi(5 
plexuses,  as  well  as  their  eoimeetioii  with  the  ereetih;  system,  e\[)laiii 
the  alai-iuiug  heni()rrha<;es  whieh  Deeasioiially  follow  wounds  ol'  the 
labia,  the  excision  of  eysts  and  tumors,  operations  on  the  perineum, 
ete.  The  sur<!;eon  need  not  antlei[)ate  any  ecmsideral^le  arterial  bleed- 
in"-  in  this  region,  although  secondary  vencHis  oozing  is  by  no  means 
uncommon,  especially  if  one  of  the  vaginal  bulbs  be  wounded.  Most 
of  the  fatal  cases  rei)orted  resulted  from  the  rupture  of  dilated  veins. 
This  dilatation  is  best  observed  during  pregnancy,  when  the  labial 
plexuses  are  mapped  out  more  clearly  than  in  the  most  carefully 
injected  anatomical  preparations.  A  rupture  of  one  of  these  varicose 
vessels,  either  by  an  injury  from  without  or  by  the  pressure  of  the 
child's  head  during  parturition,  results  in  the  formation  of  a  labial 
thrombus  which  may  attain  a  large  size.  The  rapid  development  of 
oedema  of  the  external  genitals  in  connection  with  general  venous 
obstruction  and  anasarca  is  another  striking  evidence  both  of  the 
vascularity  of  the  parts  and  of  the  free  communication  of  the  veins 
with  the  deeper  vessels. 

The  possibility  that  a  tumor  of  the  labium  may  be  a  hydrocele  or 
hernia  (even  of  the  ovary)  will  be  evident  to  the  reader  who  recalls 
the  relation  which  the  part  bears  to  the  inguinal  canal  as  the  analogue 
of  the  scrotum.  It  is  often  difficult  to  apply  the  ordinary  rules  of  dif- 
ferential diagnosis  because  of  the  thickness  of  the  adipose  tissue  cover- 
ing the  tumor. 

It  has  been  stated  that  the  vestibule  is  entirely  concealed  by  the 
apposition  of  the  labia  majora  when  the  thighs  are  closely  approxi- 
mated. In  order  to  examine  this  region,  then,  it  is  necessary  to  sep- 
arate the  knees  widely  and  to  hold  the  labia  apart.  The  inexperienced 
examiner  will  be  disappointed  not  only  at  the  small  size  of  the  clitoris, 
but  at  the  indistinctness  of  the  meatus  urinarius.  The  small  "  tuber- 
cle "  which  is  said  to  form  a  sure  guide  to  the  meatus  is  quite  as  often 
absent  as  present,  while  prolapse  of  the  mucous  membrane  of  the  canal, 
polypi,  etc.  may  cause  a  complete  alteration  in  the  usual  feel  of  this 
region.  In  passing  a  catheter  by  the  sense  of  touch  the  physician  will 
do  well  to  disregard  the  rule  laid  down  in  most  of  the  textbooks  on 
obstetrics,  and,  instead  of  searching  the  vestibular  area  for  a  "  guide  " 
to  the  meatus,  to  look  for  it  at  once  in  the  median  line  immediately 
above  the  vaginal  outlet.  Introduce  the  fore  finger  into  the  vagina, 
with  the  volar  surface  uppermost,  locate  the  meatus,  and  pass  the 
catheter  along  the  finger  as  a  guide.  In  this  way  we  not  only  avoid 
entrance  into  the  vagina,  but  can  feel  and  direct  the  instrument  as  it 
glides  along  the  urethra.  It  should  not  be  forgotten  that  the  glandulse 
vestibulse  minores,  which  lie  one  on  either  side  of  the  urethral  opening, 
mav  become  enlarged,  forming  culs-de-sac  admitting  the  tip  of  a  catheter. 


116         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

Although  the  sensitiveness  of  the  cHtoris  has  undoubtedly  been  exag- 
gerated, it  is  desirable  to  avoid  fingering  it  during  a  vaginal  examina- 
tion :  this  may  always  be  accomplished  by  sweeping  the  finger  over  the 
perineum  to  reach  the  vulvar  orifice,  instead  of  beginning  at  the  ves- 
tibule and  passing  it  downward.  The  clitoris  may  become  the  seat  of 
epithelioma  or  hypertrophy,  so  that  excision  of  the  organ  is  indicated  : 
as  a  smart  hemorrhage  may  follow  a  wound  of  the  dorsal  artery,  the 
galvanic  6craseur  is  usually  preferable  to  the  knife. 

The  surgical  anatomy  of  the  vulvo-vaginal  glands  is  not  without 
interest.  They  may  become  enlarged  from  simple  cystic  dilatation,  or  as 
the  result  of  inflammation  extending  from  the  vaginal  mucosa,  which 
is  continuous  with  the  lining  membrane  of  the  gland  and  its  duct. 
Under  the  latter  circumstances  the  presence  of  gonorrhoea  should  be 
strongly  susj^ected.  The  danger  of  severing  the  duct  of  the  gland  in 
the  minor  obstetric  operation  known  as  "  episiotomy "  has  been  exag- 
gerated :  the  accident  could  only  occur  through  carelessness  or  want  of 
skill  on  the  part  of  the  accoucheur.  The  same  remark  will  apply  to  the 
operation  of  perineorrhaphy. 

Having  considered  the  external  genitals,  we  shall  next  preceed  to  the 
description  of  the  vagina,  which  forms  a  connecting  link  between  these 
and  the  internal  generative  organs. 

Vagina. 

Syistois^yms. — Vulvo-uterine  canal ;  Grr.,  iXuzpov ;  Lat.,  vagina,  sinus 
muliebris  ;  Fr.,  vagin  ;   Ger.,  Scheide ;  It.  and  Sp.,  vagina. 

Defixitiox. — The  vagina  is  a  musculo-membranous  canal  of  variable 
dimensions,  situated  between  the  bladder  and  rectum,  extending  from 
the  uterus  to  the  vulva.  It  is  attached  below  to  the  ischio-j)ubic  rami ; 
above,  it  surrounds  the  cervix  uteri,  with  which  it  is  continuous. 

The  direction  of  the  vaginal  canal  varies  in  different  subjects  accord- 
ing to  the  position  (especially  the  degree  of  inclination)  of  the  sym- 
physis pubis.  Its  normal  axis,  as  obtained  with  the  bladder  empty, 
forms  with  the  long  axis  of  the  uterus  an  angle  described  by  some  an- 
atomists as  a  right  angle,  by  others  as  an  obtuse,  the  degree  of  obtuse- 
ness  being  determined  by  the  amount  of  distension  of  the  bladder. 
AVhen  the  woman  is  in  the  recumbent  posture  the  direction  of  the 
vaginal  axis  is  nearly  horizontal,  while  in  the  lithotomy  position  it 
forms  an  inclined  plane  extending  downward  and  backward  from  the 
\'^dva.  De  Sinety  claims  that  the  axis  of  the  vagina  is  rectilinear,  and 
that  it  is  not  correct  to  represent  it  by  a  curved  line  corresponding  with 
the  axis  of  the  pelvis,  as  is  done  in  most  works  on  obstetrics. 

The  vagina  has  been  aptly  termed  "  a  mucous  slit  in  the  pelvic  floor," 
since,  when  it  is  not  artificially  distended,  its  anterior  and  posterior 


IIYMKX.  117 

walls  an-  in  dose  contact,  and  it  ai)[)('ars  in  a  mesial  section  of  the 
pelvis  as  a  line  convex  anteriorly.  On  cnjss-section  it  is  represented 
by  a  slit,  transverse  or  ereseentic  in  an  infant,  bnt  H-shapecl  in  an  adnlt, 
the  lonjjjitndinal  limbs  of  the  H  bcin*^  convex  on  their  inner  asj)ects,  the 
horizontal  lind)  i)rojectin;2;a  little  anteriorly.  The  canal  when  distended 
shows  a  o-radual  increase  in  size  from  the  hymen  to  the  uterine  junction, 
so  that  a  [)ULstcr  cast  of  a  nulliparous  vagina  bears  a  certain  resem- 
blance to  a  truncated  cone.  In  multipara?  it  is  capable  of  great  disten- 
sion and  its  shape  is  extremely  variable.  The  length  of  the  canal  varies 
from  seven  to  eleven  centimeters,  the  average  being  seven  and  a  half. 
The  posterior  wall  is  from  one  to  tvvo  and  a  half  centimeters  longer 
than  the  anterior.  The  transverse  (and  antero-posterior)  diameter  varies 
in  nulliparae  from  three  to  four  centimeters,  in  multipara  from  six  to 
seven.  Before  entering  upon  the  anatomy  of  the  vagina  it  is  desirable 
to  glance  at  the  structure  which  forms  its  lower  boundary. 

Hymen. 

Synonyihs. — Virginal  membrane  ;  Gr.,  bivr^v  ;  Led.,  claustrum  vir- 
ginale,  valvula  vaginae,  zona  castitatis,  etc.  etc. ;  Fr.,  hymen  ;  Ger.y 
Hymen  ;  It.,  imene  ;  Sp.,  himen. 

Definition. — The  hymen  is  a  circular  or  ereseentic  fold  of  connect- 
ive tissue,  covered  by  mucous  membrane,  which  immediately  surrounds 
the  orifice  of  the  vagina  and  forms  the  lower  extremity  of  that  tube. 

The  hymen  is  almost  invariably  spoken  of  as  "  a  fold  of  mucous 
membrane "  which  partially  closes  the  orifice.  Budin  proved  conclu- 
sively that  it  is  anatomically  a  folding  in  of  the  entire  vaginal  wall.^ 
His  arguments  may  be  stated  briefly  as  follows :  1 .  After  removing 
entire  the  genital  organs  of  an  infant,  if  the  vulva  is  detached  and 
the  labia  minora  are  divided  transversely  the  hymen  disappears,  but  it 
reappears  on  restoring  the  parts  to  their  original  condition  ;  that  is,  the 
vagina  is  like  a  glove-finger  which  has  a  circular  opening  at  its  lower 
extremity ;  2,  the  ridges  and  columns  of  the  vagina  are  continued  on 
to  the  hymen  as  far  as  its  free  edge ;  3,  the  histology  of  the  hymen, 
which  has  been  carefully  studied  by  De  Sinety,  shows  clearly  that  it  is 
not  an  independent  fold  of  mucous  membrane ;  4,  in  the  foetus  there 
is  an  interval  of  several  millimeters  between  the  vulvar  and  vaginal 
openings.  The  hymen  surrounds  the  latter  at  as  early  a  period  as  the 
end  of  the  fourth  month.  As  the  foetus  develops  the  vaginal  orifice 
appr(jaches  the  vulvar,  until  the  hymen  finally  reaches  the  inner  border 
of  the  nymphse.  It  is  interesting  to  note  the  fact  that  the  first  trace 
of  this  fold  in  the  embryo  is  represented  by  minute  excrescences  on  the 
posterior  vaginal  Avail." 

'  ProgrH  med.,  Aug.  1879,  p.  677 ;  also  Ledru,  These  de  Paris,  1855. 
^  Am.  Journ.  ObsteL,  1878,  vol.  xii.  p.  205. 


118        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

Gh'oss  Appearance. — The  hymen  ordinarily  appears  as  a  crescentic 
fold  situated  at  the  posterior  jDart  of  the  introitus.  It  lies  loosely 
against  the  posterior  vaginal  wall,  "  like  a  jib  bellied  by  the  wind,"  ^ 
and  does  not  assume  the  appearance  of  a  tense  membrane  stretched 
across  the  orifice  unless  the  thighs  are  widely  abducted  so  as  to  sepa- 
rate the  sides  of  the  canal.  So  little  obstruction  does  this  variety  of 
hymen  offer  to  the  introduction  of  a  foreign  body  into  the  vagina  that 
it  frequently  persists  after  repeated  acts  of  coitus.  Budin  ^  states  that 
in  the  course  of  a  single  year  he  found  this  structure  intact  in  no  less 
than  seventy-five  primiparse  who  were  examined  during  labor,  so  that 
he  goes  so  far  as  to  say,  "  Ce  n'est  pas  le  mari,  mais  I'enfant,  qui  a 
enleve  a  sa  mere  ce  quon  consid6re  comme  les  marques  physiques  de  la 
virginity."  On  the  other  hand,  the  hymen  is  by  no  means  constant. 
Mauriceau  and  Buifon  deny  its  existence. 

Several  forms  of  hymen  have  been  described,  the  most  common 
being  the  crescentic ;  the  annular,  which  forms  a  complete  ring 
around  the  vaginal  outlet,  with  a  central  aperture;  the  cribriform, 
which  is  perforated  by  several  small  holes ;  and  the  fimbriated  type, 
which  has  a  fringed  edge.  The  imperforate  variety  is  of  course 
pathological. 

It  is  unnecessary  to  refer  to  the  medico-legal  importance  of  this 
structure,  since  it  is  an  accepted  fact  that  neither  is  its  presence  an  abso- 
lute proof  of  chastity  in  its  possessor,  nor,  on  the  other  hand,  does  its 
rupture  imply  that  sexual  intercourse  has  taken  place.^  Schroeder  has 
made  a  careful  study  of  the  appearance  presented  by  the  hymen  after 
rupture.  (For  a  detailed  account  of  these,  accompanied  by  drawings, 
the  reader  is  referred  to  his  original  article.*)  The  important  fact  to 
remember  in  this  connection  is  that  the  so-called  carunculse  myrtiformes 
do  not  represent  the  remains  of  the  hymen  after  its  rupture.  It  would 
seem  superfluous  to  refer  to  this  error  were  it  not  still  retained  in  popu- 
lar textbooks.  A  superficial  examination  of  the  hymen  in  a  married 
woman  Avho  has  never  borne  children  will  invariably  reveal  the  fact 
that  this  structure  persists  just  as  truly  as  in  the  virgin.  The  caruncles 
are  irregular,  fleshy  protuberances  skirting  the  vaginal  orifice,  and  are 
the  remains  of  the  sloughing  and  cicatrizing  processes  that  result  from 
childbirth.  A  careful  examination  of  these  masses  will  show  that  they 
vary  greatly  in  their  size  and  shape,  appearing  sometimes  as  mere  tags 
of  tissue,  sometimes  as  distinct  polypi,  which  result  from  injury  to 
the  vaginal  wall  as  well  as  the  hymen.  As  a  consequence  of  labor  the 
line  of  demarkation  between  the  vulva  and  vagina  is  obliterated,  the 
latter  being  really  "  unfolded,"  to  use  Budin's  expression,  so  that  its 

^  Foster,  op.  cit.  ^  Des  Lesions  traumatiques  chezla  Femme,  etc.,  1878. 

3  Comp.  Thomas,  N.  Y.  Med.  Journ.,  1859,  vol.  vi.  p.  196. 

*  See  Edinburgh  Med.  Journ.,  1877-78,  vol.  xxiii.  pp.  906-910,  for  translation. 


VAGrXA.  110 

lower  extremity  (the  liynien),  instead  of  f'onuinjr  a  ])roinineiit  fold  five 
or  six   niilliiiietei's  in  width,  is  Ihish  with  the  wall  <»!"  the  vulva. 

Anatomy. — a.  dross. — AlthouLih  it  |)resents  the  appearaiux;  of  a 
thin  niemhrane  when  viewed  iVoni  the  front,  a  eross-scetion  of  the 
hymen  has  a  somewhat  trian«inlar  ontline,  the  base  of  the  triangle  rest- 
ing upon  the  vaginal  wall,  while  its  apex  corre.spond.s  with  the  free 
vih^c.  As  will  he  seen  even  with  the  naked  eye,  the  hymen  eonsists  of 
a  double  fold  of  nuieous  membrane,  between  whieh  is  a  delicate  layer 
of  connective  tissue  that  is  directly  continuous  with  that  of  the  vaginal 
Avail.  Numerous  blood-vessels  may  also  be  traced  from  the  vaginal 
])lexuses  into  the  hymen,  in  which  they  ramify  as  far  as  its  free  edge. 

B.  3Ii)U(f('. — The  mucous  membrane  is  covered  by  a  layer  of  pave- 
ment e])ithelium,  that  on  the  upper  surface  of  the  hymen  being  contin- 
uous with  the  vaginal  epithelium,  on  its  lower  surface  with  that  of  the 
vulva.  Beneath  the  epithelial  layer  is  a  dense  network  of  fibrous  tissue, 
in  which  are  numerous  clastic  and  a  few  smooth  muscular  (?)  fibres. 
jSIany  papillae  extend  upward  into  the  epithelial  layer.  Xot  only  is 
there  a  rich  capillary  plexus  in  the  midst  of  this  tissue,  but  numerous 
fine  nerve-fibrils  Avill  be  seen  under  the  microscope,  the  ultimate  termi- 
nations of  Avhich  are  not  certainly  known.  All  of  these  structures  may 
be  traced  from  the  vaginal  wall.^ 

Walls  of  the  Yagixa. — There  are  two,  the  anterior  and  the  pos- 
terior :  both  have  a  somewhat  triangular  shape,  the  bases  of  the  triangles 
being  uppermost.  The  former  extends  from  the  upper  edge  of  the  ori- 
ficium  vaginse  to  the  cervix,  in  front  of  which  it  expands  to  form  the 
anterior  cul-de-sac.  Its  length  averages  five  centimeters,  the  lower  three 
centimeters  being  intimately  united  Avith  the  urethra  and  neck  of  the 
bladder,  forming  the  urethro-A'aginal  septum.  The  anterior  cul-de-sac 
is  a  shalloAV  pouch  in  front  of  the  cervix  Avhich  varies  in  depth  accord- 
ing to  the  amount  of  inclination  of  the  uterus.  The  mucous  membrane 
coA'ering  the  anterior  Avail  is  throAvn  into  numerous  folds  or  projections, 
which  are  most  marked  near  the  A^ulva  and  gradually  disappear  toward 
the  upper  end  of  the  canal.  These  folds  are  distinguished  as  temporary 
and  permanent,  the  former  disappearing  AA'hen  the  vagina  is  distended. 
The  latter  consist  of  series  of  transA^erse  ridges  that  extend  obliquely 
upAvard  and  outAvard  from  a  median  longitudinal  ridge  knoAvn  as  the 
anterior  column.  The  transA'erse  cristse  are  themseh'es  composed  of 
still  smaller  secondary  ridges,  AA'hich  are  covered  with  papillfe.  The 
anterior  column  may  begin  immediately  behind  the  meatus  or  at  the 

'  Budin's  view  of  the  origin  of  the  hymen  is  not  universally  accepted.  Pozzi  (Gaz. 
med.  de  Paris,  Feb.  23,  1884,  p.  86)  believes  that  it  is  an  outgrowth  from  the  fo?tal 
sinus  urogenitalis,  and  hence  that  it  is  really  a  part  of  the  vulva.  He  regards  the 
hvinen  as  the  analogue  of  the  bulb  of  the  urethra  in  the  male. 


120        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

small  tubercle  below  it,  and  it  generally  disappears  at  the  upper  third 
of  the  vagina.  It  is  not  infrequently  divided  into  two  parts  by  a 
median  longitudinal  groove ;  the  opposite  halves  may  reunite.  This 
column  may  be  situated  laterally.  The  ridges  are  most  prominent  in 
the  newborn  and  in  virgins ;  in  the  latter  they  are  remarkably  firm  to 
the  touch.  They  disappear  to  some  extent  after  childbirth,  especially  at 
the  upper  part  of  the  canal,  but  they  may  persist  near  its  lower  end  in 
the  form  of  prominent  papillae. 

The  posterior  vaginal  wall  extends  from  the  lower  edge  of  the  orifice 
to  the  cervix,  behind  which  it  forms  the  deep  pouch  known  as  the  pos- 
terior cul-de-sac.  Its  average  length  is  seven  and  a  half  centimeters. 
The  lower  four-fifths  of  this  wall  is  loosely  connected  with  the  rectum, 
forming  the  recto-vaginal  septum.  There  is  a  posterior  column  with 
transverse  ridges  extending  outward  from  it,  but  these  are  not  so  prom- 
inent as  those  on  the  anterior  wall. 

The  roof,  or  fornix,  of  the  vagina  is  the  upper  part  of  the  tube 
where  it  surrounds  the  cervix.  Its  extent  and  peculiar  dome-like 
appearance  are  only  seen  when  the  canal  is  dilated,  the  anterior  and 
posterior  walls  being  normally  in  contact  with  the  cervix.  The  pos- 
terior cul-de-sac,  or  fornix,  has  at  least  twice  the  depth  of  the  anterior, 
on  account  of  the  higher  attachment  of  the  vagina  behind  the  cervix. 
This  difference  is  not  ajjpreciated  on  viewing  the  vagina  and  uterus 
externally,  because  of  the  intimate  union  between  the  two  organs.  The 
lateral  fornices  are  simply  the  portions  of  the  vaginal  roof  which  lie  on 
either  side  of  the  cervix ;  they  have  no  appreciable  depth,  and  serve  to 
connect  the  anterior  and  posterior  culs-de-sac.  The  important  relations 
of  the  latter  will  be  mentioned  subsequently. 

It  is  unnecessary  to  give  more  than  a  passing  reference  to  the  changes 
in  the  vagina  which  ensue  from  senile  involution — shortening  of  the 
longitudinal  and  transverse  diameters,  narrowing  of  the  entire  canal, 
atrophy  of  the  mucous  membrane,  with  obliteration  of  the  rugse — or  to 
the  general  hyperplasia  which  results  from  pregnancy.  It  shares  in 
the  changes  which  occur  in  all  of  the  pelvic  organs  under  the  conditions 
mentioned. 

AiSrATo:MY. — a.  Gross. — The  wall  of  the  vagina  consists  of  three  layers 
— an  external,  composed  of  connective  tissue ;  a  middle,  of  unstriated 
muscle ;  and  an  inner  mucous  layer.  The  connective  tissue  serves  to 
unite  the  vagina  firmly  to  adjacent  organs ;  in  fact,  Cruveilhier  does 
not  regard  it  as  belonging  properly  to  the  wall  of  the  canal.  It  serves 
also  to  support  the  external  plexus  of  veins.  The  fibres  of  the  mus- 
cular layer  do  not  form  distinct  strata,  but  interlace ;  they  have,  how- 
ever, been  divided  into  two  sets,  those  having  a  general  longitudinal 
direction,  and  those  which  are  circular  or  oblique.  Authorities  differ 
as  to  the  relative  position  of  the  fibres,  some  stating  that  the  innermost 


VAGiyA.  121 

ones  aiv  loiioltudiiial/  while  Ureisky-  alliriiis  tliat  they  are  usually  cir- 
cular. He  admits  that  in  the  anterioi-  eolininis  the  I'oriner  aiTanuenient 
prevails.  Luschka'  describes  a  hinidle  of"  striated  nni.-cidar  fibres 
wlilcli  suiToiinds  the  lower  end  of  the  va<i;ina  and  also  encii-clcs  the 
urethral   oi'iliee  (sphincter  va<;-ina'). 

'V\\o  nuicons  nicinbrane  of"  the  vaj^ina  varies  in  thickness  from  one 
to  one  and  a  hall"  millimeters,  and  extends  l"i'om  the  free  edge  of"  tiie 
hymen  to  the  cervix  uteri,  over  which  it  is  rellected.  Its  color  is  nor- 
mally rosy  red,  but  it  may  vary  from  a  light  pink  to  a  dark  pui'ple  or 
slate  color,  the  latter  hue  fre([uently  appearing-  during  ])regnancy.  It 
is  closely  united  to  the  subjacent  nuiscular  layer,  and  is  disj)osed  in  the 
form  of  columns  and  transverse  ridges,  as  before  mentioned  :  a  section 
through  one  of  the  colunuis  shows  that  the  nnicous  meml)rane  is  nnich 
thicker  here  than  it  is  in  the  hollow  between  the  ridges,  and  that  it  is 
also  more  vascular.  Numerous  papillje  cover  the  mucous  surface ;  these 
increase  in  size  during  pregnancy.  A  small  amount  of  acid  mucus  is 
normally  present  on  the  walls  of  the  vagina.  The  secretion  is  aug- 
mented during  pregnancy  and  the  menstrual  period.  The  vaginal  wall 
has  not  the  same  thickness  throughout.  At  the  upper  part  of  the  canal 
it  measures  from  two  to  three  lines,  A\hile  near  the  outlet  it  is  from  five 
to  six  lines  thick.  This  difference  is  due  to  the  variation  in  thickness 
of  the  muscular  layer. 

Vascular  Supply. — The  vagina  receives  arterial  branches  from  sev- 
eral sources.  Besides  the  vaginal  arteries,  which  spring  generally  from 
the  anterior  divisions  of  the  internal  iliacs  below  the  origin  of  the  ute- 
rine arteries,  and  give  oif  several  parallel  twigs  which  ramify  ujDon  the 
lateral  wall  of  the  tube,  branches  from  the  uterine  supply  its  upper  end, 
while  the  pudendal  arteries  send  branches  to  its  lower  extremitv.  All 
of  these  vessels  anastomose  freely  with  one  another,  with  those  of  the 
opposite  side,  and  with  the  uterine,  vesical,  and  rectal  arteries.  H}'rtl 
figures  an  azygos  branch  which  has  a  longitudinal  course  along  the 
anterior  vaginal  wall  and  empties  into  the  circular  arter}^  of  the  cervix. 

The  vaginal  veins  are  disposed  in  the  form  of  plexuses  that  form 
complete  vascular  sheaths  around  the  canal,  one  being  external  to  the 
muscular  layer,  while  the  other  lies  just  beneath  the  mucous  membrane. 
These  communicate  freely  with  the  pudendal,  vesical,  and  hemorrhoidal 
plexuses  below,  and  with  the  plexuses  of  the  broad  ligament  above. 
Some  of  these  communicating  networks  have  received  special  names. 
Thus  a  collection  of  veins  situated  on  either  side  of  the  fornix  has  been 
called  the  utero-vaginal  plexus  ;  another  in  the  vesico-  or  urethro-vagi- 
nal  septum,  the  vagi  no- vesical  plexus.*  All  of  these  veins  are  without 
valves. 

'  Henle,  Klein,  and  Frey.  2  Kranl;h.  der  Vagina,  1879,  p.  7. 

3  Op.  cil.,  p.  387.  *  Ravage,  op.  cil.,  pi.  ix.  fig.  1. 


122 


THE  ANATOMY  OF  THE  FEMALE  PELVIC  OBGASS. 


Lymphatics. — The  lymphatics  which  oome  from  the  lower  end  of  the 
vagina  unite  with  those  from  the  external  genitals  and  enter  the  ingui- 

■     •*  —  K  F^G.  42.  ^^ 


Arteries  and  Veins  of  Vagina  and  Uterus  fSa\^5^;.  j^,  ^x..v.^er  cut  at  urachus  and  turned 
forward ;  R,  rectum ;  L,  round  ligament ;  U,  uterus :  0,  ovary :  T',  vagina ;  S,  sacro-iliac 
articulation;  K,  kidney;  F,  Fallopian  tube;  P,  pubic  symphysis;  o.  pyriformis  muscle; 
h,  gluteal  muscles ;  c,  ischio-coccygeus  muscle ;  d,  internal  obturator  muscle ;  e,  e,  psoas 
muscle ;  /,  linea  alba  ;  g,  g.  ureters  ;  h,  obturator  nerve  :  i,  internal  inguinal  ring :  1,  abdom- 
inal aorta ;  2,  inferior  mesenteric  artery  ;  3,  S,  common  iliac  arteries  ;  4.  external  iliac  artery ; 
5,  vena  cava ;  6,  renal  veins ;  7,  7,  common  iliac  veins ;  8,  external  iliac  vein ;  9,  internal 
iliac  artery ;  10,  gluteal ;  11,  ileo-lumbar  ;  12,  sciatic  ;  13,  pudic ;  14,  obturator ;  15,  epigastric 
veins ;  17,  uterine  veins ;  18,  vagino-vesical  venous  rete ;  19,  spermatic  veins ;  20,  bulb  of 
ovary;  21,  vein  to  round  ligament;  22,  Fallopian  veins. 

nal  glands.     The  vessels  from  the  upper  three-fourths  of  the  vagina 
are  joined  by  branches  from  the  cervix  uteri  and  bladder,  and  termi- 


F.167X1. 


123 


nato  in  tlio  internal  iliao  o;lan(ls.'  The  nervous  supply  of  the  vajxina 
is  (IcrJNrd  almost  entirely  Ironi  the  synipallietie  system;  branches  irom 
the  interioi-  hypogastric  plexuses  form  a  network  around  the  canal, 
^vhieh    is  eoutimious   with   that  M'hieh   surrounds  the  uterus. 


Fig.  4  1. 


Longitudinal  Section  of  the  Vaginal  Wall. 


Transverse  Section  of  the  same  i  Breisky). 


a,  mucous  membrane ;  b,  muscular  layer,  including  a,  circular,  and  p,  longitudinal  fibres ;  c, 
fibrous  layer,  containing  fat. 

B.  3Iinufe. — A  cross-section  through  the  vaginal  wall  presents  the 
following  appearance  under  the  microscope :  There  is  an  external  layer 
of  fibrous  tissue,  in  the  midst  of  which  will  be  seen  numerous  large 
veins  belonging  to  the  so-called  plexus  venosus  vaginalis.     Around 

^  Accordin,?  to  Le  Bee  (Gaz.  hehdom.,  April  15,  1881),  the  united  lymphatics  of  the 
cervix  and  upper  part  of  the  vagina  rtin  beneath  the  base  of  the  broad  ligament,  and 
open  into  some  small  glands  around  the  obturator  foramen. 


124        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

these  are  bundles  of  smooth  muscular  fibres,  the  presence  of  which 
suggests  a  resemblance  to  true  cavernous  tissue.  Running  with  the 
veins  are  large  lymphatics,  some  of  which  are  dilated  so  as  to  form 
sinuses.  More  internal  to  the  fibrous  layer  is  the  muscular  stratum,  in 
w^hich  the  outer  fibres  will  be  divided  more  or  less  transverselv,  while 
the  inner  have  a  longitudinal  course.  Between  and  among  these  are 
other  fibres  that  cross  one  another  in  all  directions.  Lymphatic  plexuses 
are  distributed  between  the  bundles.  Internal  to  the  muscular  coat  is 
the  submucous  layer  of  loose  areolar  tissue  which  supports  a  second 
venous  network,  the  vessels  appearing  to  be  much  smaller  than  those 
forming  the  external  plexus,  and  having  a  general  course  parallel  to 
the  course  of  the  canal.  Another  set  of  lymphatics  is  present  in  this 
tissue,  the  vessels  being  relatively  of  large  size  and  having  valves.  The 
mucous  membrane  of  the  vagina  consists  of  dense  fibrous  tissue,  in  the 
midst  of  which  are  numerous  elastic  fibres,  over  which  are  several  layers 
of  stratified  pavement  epithelium.  This  mucosa  with  its  epithelium  is 
not  only  thrown  into  large  folds,  but  forms  secondary  elevations  or 
papillae,  in  each  of  w^hich  is  a  capillary  loop.  In  sections  of  the  mucous 
membrane  of  the  fornix  these  loops  are  single,  but  in  the  large  papillae 
that  cover  the  rugse  near  the  introitus  there  is  quite  a  complicated  vas- 
cular network.  The  rugae  have  a  different  structure  from  the  general 
mucosa,  since  they  contain  large  venous  plexuses  sm-rounded  by  bun- 
dles of  muscular  fibres,  as  in  cavernous  tissue. 

The  mucous  membrane  is  richly  supplied  with  lymphatics :  L5w- 
enstein  has  described  lymph-follicles  similar  to  those  in  the  large 
intestine.^ 

The  existence  of  true  secreting  glands  in  the  vaginal  mucous  mem- 
brane has  not  been  postively  determined.  Von  Preuschin^  has  de- 
scribed tubular  crypts  or  glands  in  the  region  of  the  fornix  which  are 
lined  with  columnar  (ciliated?)  epithelium.  Robin,  Cadiat,  Sappey, 
De  Sin6t}^,  and  many  others  deny  the  existence  of  glands  in  the 
vagina,  and  believe  that  the  vaginal  mucus  is  an  exudation  from  the 
free  surface  of  the  mucosa,  and  not  a  true  secretion. 

Nerves  ramify  throughout  the  muscular  coat  and  communicate  vv^ith 
one  another  and  with  the  ganglia  that  are  present  in  considerable  num- 
bers. There  is  a  plexus  beneath  the  epithelial  layer,  the  terminal  fila- 
ments from  which  enter  structures  known  as  end-bulbs. 

Relatioxs. — Anteriorly,  the  vagina  is  connected  with  the  bas  fond 
and  neck  of  the  bladder  by  means  of  a  quantity  of  dense  areolar  tissue. 
This  union,  which  occurs  over  the  upper  half  of  the  vagina,  is  not  as 
intimate  as  that  between  the  vagina  and  urethra,  yet  the  term  "  vesico- 
vaginal septum  "  is  applied  to  the  entire  thickness  of  the  tissues  sepa- 
rating the  two  cavities.     It  is  formed  by  the  anterior  wall  of  the  vagina, 

^  Centralbl.f.  Tried.  Wissenschaft,  1871,  p.  546.  ^  Virch.  Arch.,  Bd.  Ixx.  p.  6. 


VAGIXA.  125 

the  jiostcrior  wall  of"  the  hhuUlor,  and  the  layer  ol"  (•(inneetive  tissue 
between  thcni,  in  which  is  the  va,ii;inu-vesical  plexus  of  veins.  The  hjwer 
halt"  of  the  anterior  va<i;inal  wall  is  so  firmly  united  to  the  urethra  that  the 
latter  is  literally  "  imbedded  in  it,"  as  Quain  describes  it,  the  vmion  re- 
sultin*!:  in  the  f"ormation  of  the  "  urethro-vaginal  septum,"  Mhieh  includes 
the  anterior  three-fourths  of  the  urethra.  The  posterior  vaginal  wall 
is  looselv  connected  over  the  middle  two-fourths  of  its  extent  with  the 
rectum,  one  or  more  layers  of  connective  tissue  being  interposed.  The 
correctness  of  the  term  "  recto-vaginal  septum  "  as  applied  to  this  union 
has  been  properly  questioned,  since  the  connection  is  hardly  close  enough 
to  warrant  it.  Over  its  upper  fourth  the  vagina  is  separated  from  the 
rectum  by  the  cul-de-sac  of  Douglas,^  while  below  the  level  of  the  pel- 
vic floor  the  perineal  body  intervenes  between  the  two  canals. 

Laterally,  the  vagina  receives  the  attachment  of  the  pelvic  diaphragm 
— that  is,  the  levatores  aui  muscles  and  the  fascia  covering  them — while 
it  is  in  immediate  relation  with  the  large  venous  plexuses  already  men- 
tioned. 

The  relations  of  the  fornix  are  so  important  as  to  deserve  a  separate 
description.  The  anterior  cul-de-sac  is  at  least  an  inch  and  a  half  from 
the  vesico-uterine  peritoneal  fold.  Above  and  well  to  its  outer  sides 
are  the  ureters,  which  here  bend  downward  and  inward  to  enter  the 
bladder.  The  lateral  fornices  are  in  relation  with  the  bases  of  the 
broad  ligaments  and  the  vessels  that  pass  along  and  below  them.  The 
posterior  cul-de-sac  is  covered  by  the  anterior  fold  of  peritoneum  which 
forms  the  pouch  of  Douglas,^  some  areolar  tissue  being  interposed,  and 
descends  for  an  inch  or  more  on  the  posterior  vaginal  wall.  AVhen  the 
bladder  is  empt^'  a  coil  of  intestine  may  rest  against  the  peritoneum 
covering  the  fornix. 

Peactical  Deductions. — The  hymen  presents  numerous  varia- 
tions as  regards  shape,  thickness,  distensibilit^-,  etc.  The  diagnosis  of 
imperforate  hymen  should  not  be  made  too  hastily,  since  there  may  be 
a  minute  opening  sufficient  to  permit  the  escape  of  the  menstrual  blood, 
vet  so  small  as  to  be  readily  overlooked.  It  is  difficult  to  form  a  cor- 
rect idea  of  the  true  size  of  the  hymeneal  opening  in  virgins  unless  the 
parts  are  relaxed  by  an  anaesthetic :  such  patients  should  be  examined 
under  ether,  when  the  finger  may  be  easily  introduced  through  a  vulvo- 
vaginal outlet  which  before  appeared  to  be  hermetically  sealed.  The 
presence  or  absence  of  the  hymen  is  now  regarded  as  of  small  medico- 
legal importance,  except  in  cases  of  rape,  where  evidences  of  recent 

^  The  depth  of  Douglas's  pouch  is  subject  to  wide  variations  within  normal  limits. 
De  Sinety  states  that  the  peritoneum  descends  on  the  posterior  vaginal  wall  only  to  a 
distance  of  12-15  mm.     Tillaux  assigns  3  cm.  as  the  average  depth  of  the  pouch. 

^  According  to  Hart  and  Barbour,  only  one-third  of  an  inch  of  tissue  separates  the 
posterior  fornix  from  the  peritoneum. 


126        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

rupture  may  be  significant.  It  should  not  be  forgotten  that  an  intact 
fimbriated  hymen  may  simulate  rupture.  The  carunculse  myrtiformes, 
on  the  contrary,  are  of  value  as  pointing  to  a  previous  parturition ;  it 
is  impossible  to  conceal  this  sign  of  childbirth.  From  its  position  the 
hymen  shares  in  inflammatory  conditions  of  the  vagina  and  vulva. 
When  inflamed  it  is  extremely  sensitive,  as  might  be  inferred  from  its 
nerve-supply. 

The  anatomical  relations  of  the  vaginal  canal  are  of  extreme  import- 
ance clinically  :  it  is  impossible  for  the  physician  to  make  an  intelligent 
digital  examination  unless  he  has  them  constantly  before  his  mind, 
while  the  surgeon  will  find  it  necessary  to  keep  his  regional  anatomy 
ever  fresh.  This  remark  applies  particularly  to  the  fornices,  which  lie 
in  such  close  proximity  to  the  internal  pelvic  organs. 

The  fusion  of  the  urethral  and  vaginal  walls  to  form  the  urethro- 
vaginal septum  is  interesting  surgically.  Because  of  this  close  union, 
as  well  as  of  the  firm  connections  of  the  urethra,  pure  urethrocele,  a& 
compared  with  cystocele,  is  not  common ;  redundancy  of  the  vaginal 
tissue  is  often  mistaken  for  this  condition.  The  thickness  of  the  sep- 
tum, as  well  as  its  vascularity,  will  be  apparent  during  the  performance 
of  the  "  buttonhole  "  operation.  The  looser  connection  of  the  bladder 
with  the  upper  part  of  the  anterior  vaginal  wall  explains  the  greater 
range  of  mobility  of  the  former  organ,  while  the  union  between  the 
two  is  sufficiently  intimate  to  render  cystocele  a  common  aifection.  It 
is  important  clinically  to  distinguish  prolapsus  vaginse  (or  descent  of 
the  vaginal  wall  loithout  the  bladder)  from  cystocele  :  the  former  usually 
accompanies  prolapsus  uteri,  and,  as  the  reader  must  infer  from  his 
knowledge  of  the  anatomical  relations,  is  a  rare  condition.  In  many 
cases  of  supposed  prolapsus  uteri  in  old  women  the  displacement  is 
really  a  cystocele  vaginalis  due  to  loss  of  tone  of  the  tissues,  which 
will  not  be  corrected  by  simply  elevating  the  uterus  with  tampons  or 
pessaries. 

The  surgeon  finds  a  convenient  access  to  the  base  of  the  bladder 
through  the  vagina,  cystotomy  and  lithotomy  being  simple  operations 
in  the  female :  the  hemorrhage  is  insignificant,  and  there  is  no  danger 
of  wounding  important  structures  as  long  as  the  incision  is  made  ver- 
tically and  in  the  median  line. 

The  anterior  fornix  is  a  region  of  far  less  importance  than  the  pos- 
terior. Through  it  the  body  of  the  uterus  is  distinctly  felt  when  that 
organ  is  in  a  position  of  physiological  anteversion,  while  the  angle  in 
cases  of  anteflexion  is  apparent  to  the  least  practised  touch.  Fibroids 
on  the  anterior  aspect  of  the  uterus,  enlargement  of  the  organ  from 
various  causes  (especially  pregnancy),  the  presence  of  the  foetal  head, — 
all  these  objects  are  accessible  through  the  anterior  fornix,  especially 
with  the  patient  in  Sims' s  position.    Surgically,  we  may  be  called  upon 


VAOINA.  127 

to  n|)cii  the  aiiti'fior  poiicli  in  the  tipiTatiuiis  ol"  >ii|)r;i\';i^iii;il  cxcir-ioii 
(il'tlic  ccfsix  and  \auiiial  liystercctoiiiy — a  pi'dccilurc  rc(|iiin'ii^- >(,|||(. 
can',  not  so  imicli  Iroiii  the  (laiiiici"  of  |H"fiiiatur<'ly  opciiiii;;-  (he  jiciMto- 
nonl  cavitv  ami  iiijuriiii;-  (he  intotiiic,  as  iVoiii  tlic  liahilitv  of"  ciitcriii;^- 
the  hiadilcr.  The  pcritoiiciiiii  lies  \i'\<^\[  ii|)  oiil  of  (he  \va\',  hut  the 
hlatldiT  is  so  near  to  tUv  I'nw  of  incision  tliat  the  only  safety  lies  in 
kcepinji"  close  to  the  ntorns,  while  the  exact  jiosition  of  the  hladder  is 
iiuliciited  hy  introdueint;-  a  sound  into  it.  'IMie  readei"  who  witnesses 
for  the  first  time  this  staj;eof  a  kolpo-hysterectoniy  will  he  snrjirised  at 
the  comparative  ease  with  which  the  hladder  can  he  separated  from  its 
utero-vajijinal  ct)nncctions,  as  well  as  at  the  slight  amonnt  of  hlcedintj!;. 
The  ])eritoneal  cavitv  has  heen  opened  thron^h  the  anterior  fornix  for 
the  removal  of  a  small  snhperitoneal  fihroid/ 

The  bases  of  the  hroad  ligaments  are  directly  accessible  to  the  exam- 
ining finger  through  the  lateral  fornices — a  point  of  importance  clinical- 
ly, since  it  enables  the  gynecologist  to  determine  the  presence  of  inflam- 
matoiy  processes  or  their  results  (adhesions)  extending  outward  from  a 
lacerated  or  cjiitheliomatous  cervix.  The  pulsations  of  the  uterine 
artery  can  often  be  felt  through  the  vaginal  roof,  especially  during  preg- 
nancy, while  it  is  not  difficult  to  reach  and  control  both  vessels  by  liga- 
ture or  forceps  as  a  })reliminary  step  in  vaginal  hysterectomy  :  on  the 
other  hand,  the  venous  oozing  may  be  copious  and  impossible  to  check 
except  by  continued  ])ressure. 

The  anatomical  importance  of  the  posterior  fornix  is  evident  at  a 
glance.  It  lies  in  close  proximity  to  the  peritoneal  cavity.  Remem- 
ber that  the  depth  of  Douglas's  pouch  is  variable,  and  that  the  perito- 
neum may  rarely  dip  down  between  the  rectum  and  vagina  so  low  as 
to  be  wounded  in  operations  on  the  posterior  vaginal  Avail.  On  the 
<^ther  hand,  the  lowest  point  in  the  pouch  may  barely  reach  the  level 
of  the  fornix.  It  is  hardly  necessary  to  call  attention  to  the  various 
objects  Avhich  may  be  touched  through  the  post(>rior  fornix,  since  this 
subject  belongs  to  the  section  on  diagnosis.  The  distinctness  with 
which  prolapsed  ovaries  may  sometimes  he  felt  is  quite  startling  to 
the  tyro,  so  that  he  almost  forgets  that  they  are  separated  from  his 
finger  by  a  septum  composed  of  several  distinct  layers  of  tissue. 
The  beginner  should  become  perfectly  fiimiliar  with  the  feel  of 
the  sacro-uterine  ligaments,  so  that  he  will  not  infer  the  presence  of 
inflammation  in  them  simply  because  they  happen  to  be  better  devel- 
oped than  usual.  As  to  the  question  of  the  presence  or  absence  of  coils 
of  small  intestine  in  Douglas's  pouch,  the  reader  need  only  observe  that 
if  the  posterior  cul-de-sac  be  opened  through  the  vaginal  roof,  the 
patient  being  on  her  back,  the  proximity  of  the  intestine  will  frequ(>ntly 
be  demonstrated  in  a  maimer  unpleasant  to  the  operator.     Practically, 

'  Mann,  Am.  Journ.  Obstet.,  June,  1885. 


128         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

then,  vaginal  hysterectomy  is  best  performed  ^vith  the  woman  in  the 
left  lateral  posture,  so  that  the  intestines  may  gravitate  away  from  the 
cul-de-sac.  The  nearness  of  the  gut  to  the  vaginal  roof  is  proved  by 
the  occasional  occurrence  of  enterocele.  The  frequency  of  suppuration 
in  the  subperitoneal  sj)ace  adjacent  to  the  posterior  fornix,  and  the  tend- 
ency of  abscesss  to  point  in  this  region,  are  well  known.  Not  only  a 
pelvic  abscess,  but  a  peritoneal  efPnsion  or  an  intrapelvic  cyst,  is  easily 
reached  by  the  aspirator-needle  through  the  vaginal  roof.  Vaginal 
ovariotomy  or  salpingotomy  is  a  tempting  operation  in  many  cases,  but 
its  difficulties  are  much  greater  than  they  appear :  the  operator  can 
never  be  sure  that  in  allowing  the  stumps  to  retract  into  the  cavity 
he  has  not  released  some  bleeding  vessels  which  cannot  be  secured. 
Theoretically,  drainage  through  the  vaginal  vault  should  be  perfect; 
practically,  it  is  not,  and  the  danger  of  sepsis  is  great.  Abscesses  and 
suppurating  adherent  cysts  are  not  always  opened  with  impunity 
tlirough  the  fornix :  severe  hemorrhage  occasionally  follows  the  use 
of  the  knife ;  hence  the  thermo-  or  galvano-cauter}-  is  preferred  by 
careful  operators. 

The  ■  posterior  vaginal  wall  is  more  liable  to  become  prolapsed  than 
the  anterior,  since  it  is  connected  with  the  rectum,  as  low  as  the  apex 
of  the  perineal  body,  by  the  recto-vaginal  process  of  the  pelvic  cellular 
tissue :  that  this  process  is  hardly  thick  enough  to  constitute  a  distinct 
septum  will  be  evident  on  passing  the  finger  into  the  rectum. 

The  attachments  of  the  vaginal  tube  are  important.  By  reason  of 
its  union  with  the  cervix  uteri  any  pressure  or  traction  exerted  upon 
either  fornix  is  transmitted  directly  to  the  cervix  and  indirectly  to  the 
body  of  the  uterus.  Hence  pressure  upon  the  posterior  fornix  (by 
tampons  or  pessaries)  fends  to  draw  the  cervix  backward  and  to  throw 
the  body  foru^ard,  and,  conversely,  distension  of  the  anterior  fornix  by 
a  foreign  body  will  tend  to  lift  the  anteverted  fundus  to  a  slight  extent 
as  the  cervix  is  drawn  forward.  The  practical  application  of  this  gen- 
erally accepted  fact  is  this :  A  movable  uterus  (ante-  or  retroverted)  is 
affected  by  a  pessary  or  tampon,  while  T^-ith  an  ante-  or  reflexed  organ 
the  angle  of  flexion  is  simply  increased  by  distending  either  fornix. 

It  is  well  to  bear  in  mind  the  level  at  which  the  vaginal  roof  is 
attached  to  the  cersax,  and  the  fact  that,  as  the  result  of  contraction 
following  old  lesions,  the  infra-  and  supravaginal  portions  of  the  cervix 
may  be  practically  continuous.  In  repairing  a  laceration  of  the  cervix 
which  has  involved  the  vaginal  roof,  a  careless  operator  might  readily 
open  into  the  subperitoneal  cellular  tissue  and  expose  his  patient  to  the 
chance  of  septic  absor^^tion.  AA^ien  the  cervix  is  atrophied  and  the 
laceration  has  been  deep,  resulting  in  the  formation  of  an  extensive 
cicatrix,  the  accident  is  not  an  uncommon  one.  Fortunately,  compli- 
cations are  rare  if  the  sutures  are  carefiillv  inserted  and  antiseptic  injec- 


VAGINA.  129 

tidiis  tire  (liorniiiihly  u^cd.  in  ;iiii|)iit:iti(tii  ol"  tlic  ccrx'i.x  (Inv  lixpcr- 
tropliy  or  cpitliclioiMa)  it  is  easy  to  R'liiovc  at  the  same  time  a  puilioii 
ol"  the  va<i;iiial  rool",  and  thus  to  open  into  the  subperitoneal  or  perito- 
neal cavity — an  accident  which  is  ibrtunately  not  followed  by  fatal 
conseciuences  so  often  as  mi<;ht  be  supposed. 

The  relations  of  the  vagina  to  the  pelvic  diaj)lnagni  will  be  con- 
sidered in  another  place. 

A  few  of  the  general  features  of  the  canal  deserve  mention.  W'c 
have  seen  that  it  is  normally  a  slit,  not  an  open  tube;  it  assumes  the 
latter  character  only  \\1umi  its  walls  are  artificially  separated.  The 
phenomena  observed  on  retracting  the  jiosterior  wall  by  tiie  finger  or 
a  speculum,  an  well  as  the  influence  of  i)osture  on  the  size  and  direction 
of  the  vagina,  are  familiar  to  every  one  through  the  classical  description 
of  Sims.  Some  idea  of  the  resistance  offered  by  the  pubo-coccygeus 
muscle  may  be  gained  by  endeavoring  to  examine  a  patient  with  vagi- 
nismus before  and  after  an  anesthetic  has  been  administered.  The 
great  distensibility  of  the  vagina  is  seen  during  parturition ;  but  it 
should  not  be  forgotten  that  in  distending  it  encroaches  upon  both  the 
rectum  and  nrinary  tract.  In  tamponing  for  uterine  hemorrhage,  there- 
fore, the  tampons  should  be  so  arranged  that  pressure  is  exerted  upon 
the  former  rather  than  upon  the  latter  canal.  Advantage  is  taken  of 
the  distensibility  of  the  posterior  fornix  in  the  treatment  of  retroflexion 
of  the  uterus  Avitli  fixation  and  prolapse  of  the  ovaries.  Crude  and 
mechanical  as  this  method  is,  no  better  way  of  gradually  stretching 
(or  causing  the  absorption  of?)  old  adhesions  has  yet  been  devised  than 
the  application  of  pressure  through  the  vaginal  roof  by  means  of  tam- 
pons. Doubtless  some  brilliant  results  are  obtained  in  this  way,  but 
careful  observations  at  the  examining-table,  as  well  as  experiments  in 
the  dead-house,  have  convinced  the  writer  that  it  is  frequently  impossi- 
ble to  dislodge  an  imprisoned  uterus  or  ovary  by  pressure  exerted  from 
below  through  the  posterior  fornix.  AVhoever  devises  a  safe  and  scien- 
tific method  of  overcoming  this  difficulty  will  deserve  a  place  only  a 
little  lower  than  that  of  the  pioneers  of  abdominal  surgery. 

It  is  surprising  how  the  posterior  fornix  may  be  "  ballooned  out " 
as  the  result  of  long-continued  packing :  a  pouch  so  shallow  that  it 
will  not  retain  a  pessary  may  in  this  way  be  deepened  to  the  extent  of 
from  one  to  two  inches.  A  slight  amount  of  reflection  will  convince 
the  reader  that  by  introducing  the  plug  with  the  patient  in  the  knee- 
chest  position  he  will  obtain  the  assistance  of  gravity,  both  in  replacing 
the  pelvic  viscera  and  in  deepening  the  posterior  fornix. 

The  thinness  of  the  vaginal  walls  (two  or  three  lines)  should  not  be 
forgotten  during  operations  for  rectocele  and  cystoc^le.  It  is  a  fact  of 
common  observation  that  in  denuding,  as  soon  as  the  mucous  membrane 
has  been  removed,  the  surgeon  reaches  immediately  the  large  submucous 

Vol.  I.— 9 


130        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

venous  plexus,  which  it  is  desirable  not  to  wound.  Whether,  as  Dr. 
Emmet  believes,  it  is  possible  to  penetrate  the  entire  thickness  of  the 
vaginal  wall  with  a  needle  in  posterior  colporrhaphy,  and  to  catch  up 
the  torn  fascia  outside,  it  is  impossible  to  decide,  since  no  dissections 
have  been  made  for  the  purpose  of  proving  this  statement.  In  spite 
of  the  instructions  which  are  given  in  descriptions  of  this  operation,  it 
is  probable  that  in  most  instances  it  consists  essentially  in  merely  tak- 
ing a  reef  in  the  redundant  vaginal  mucous  membrane.  The  marked 
tendency  of  the  tissues  to  stretch  proves  a  source  of  annoyance  to  the 
surgeon,  who  frequently  finds  that  a  few  months  after  the  performance 
of  plastic  operations,  undertaken  with  the  view  of  narrowing  the  canal, 
its  calibre  is  nearly  the  same  as  before. 

The  continuity  of  the  vaginal  mucosa  with  that  of  the  uterus  and 
Fallopian  tubes  is  an  anatomical  fact  of  extreme  practical  importance. 
Gonorrhoea  is  a  serious  aifection  in  the  female  :  the  physician  who,  in  the 
light  of  our  present  knowledge  of  tubal  pathology,  continues  to  regard 
it  as  an  insignificant  local  inflammation  is  certainly  not  abreast  of 
modern  ideas.  One  of  the  chief  reasons  why  gonorrhoea  in  the  female 
is  such  a  chronic  afiection  is  because  there  are  so  many  folds  in  the 
vagina  which  are  not  reached  by  the  local  applications  and  injections. 

The  normal  rugosities  of  the  vagina  are  sometimes  so  marked  that 
they  may  be  regarded  as  pathological :  the  distribution  of  the  papillae 
and  follicles  is  well  shown  in  granular  vaginitis,  a  condition  often 
present  during  pregnancy.  Cysts,  resulting  from  dilatation  of  the 
mucous  follicles,  are  not  very  common  :  they  are  usually  found  near 
the  ostium,  and  should  not  be  confounded  with  enlargements  of  the 
\'Tilvo- vaginal  glands.  They  may  be  incised  and  the  lining  mem- 
brane touched  with  a  caustic,  or  the  cysts  may  be  dissected  out  entire : 
in  the  latter  case  the  caution  with  regard  to  the  thinness  of  the  vaginal 
wall  will  not  be  unheeded.  The  same  applies  to  operations  for  the 
removal  of  polypoid  tumors,  to  curetting  for  primary  and  secondary 
epithelioma,  etc. 

The  remarks  concerning  the  nerves  and  vessels  of  the  external 
genitals  apply  also  to  those  of  the  vagina.  The  reflex  symptoms 
observed  in  vaginismus  furnish  sufficient  evidence  of  the  continuity 
of  the  pelvic  nerve-plexuses.  The  phenomena  may  be  due  to  some 
cause  entirely  outside  of  the  vagina.  There  being  two  sets  of  valveless 
veins  in  the  vaginal  wall,  which  communicate  freely  with  the  deeper 
plexuses,  any  obstruction  to  the  pelvic  circulation  or  general  engorge- 
ment will  at  once  affect  the  former.  The  blueness  of  the  mucous  mem- 
brane of  the  vagina  during  early  pregnancy  is  sufficiently  familiar,  yet 
ovarian  and  uterine  tumors  or  prolapsus  may  cause  the  same  appear- 
ance. During  operations  on  the  perineum  and  posterior  wall,  when 
the  patient  is  profoundly  etherized  the  submucous  plexuses    appear 


UTERUS.  131 

o-rcativ  (listciidcd  as  (he  imicuiis  iiiniihraiic  is  rciiioxcd.  \\'(»iiii(ls  ol 
the  va<;iiia  (»rt('ii  nivc  rise  to  |)n»fiiso  venous  lu'inorrliaj^c,  tsju-cially 
(liiriiiij;  |)r('i;iiaiicy  and  pai-tiirition.'  It  is  bettor  to  pass  a  suture 
under  (he  Wlccdin;;-  vessel  than  t<t  endeavor  to  isolate  it  or  to  lijrate 
en  inawr.  Hot  water  is  an  excellent  styptie  durin<^  i)lasti(;  ojjera- 
tions.  On  the  same  principle,  copious  injeetions  of  water  at  a  liij^li 
teini)erature  (110°  F.),  the  hips  beiuji;-  elevated  in  order  to  favor  the 
i-eturn  of  the  venous  blood,  frequently  cut  short  an  attack  of  acute 
vaginitis.  Even  those  who  question  the  antiphlogistic  action  of  hot 
water  in  deep  intrapelvie  inHanmiation  will  not  doubt  its  value  in 
cases  wher(>  it  can  be  applied  so  directly  to  the  affected  spot. 

The  union  of  the  lymphatics  of  the  lower  fourth  of  the  vagina  with 
those  of  the  external  genitals  Iuls  already  been  mentioned.  Le  Bee's 
statement  that  the  lymphatics  of  the  upper  three-fourths  of  the  canal 
unite  with  those  of  the  cervix  and  pass  below  the  broad  ligaments  to 
the  obturator  glands,  and  that  they  eommunicatc  freely  with  the  ingui- 
nal glands,  seems  to  be  borne  out  clinically  by  the  fact  that  the  latter 
are  commonly  involved  in  malignant  disease  of  the  upper  portion  of 
the  canal.  The  hopelessness  of  eifccting  a  radical  cure  in  such  cases  is 
sufficiently  evident.  The  blood-  and  lymphatic-supply  of  the  cervix 
and  upper  part  of  the  vagina  being  practically  the  same,  it  is  evident 
that  the  prognosis  in  malignant  disease,  as  regards  its  extension  to  sur- 
rounding tissues,  Avill  be  nearly  identical  for  both  regions. 

Uterus. 

Synoxyjvis. — Eng.,  womb  ;  Gr.,  uazipa  ;  Lat.,  matrix  ;  Fr.,  ma- 
trice  ;    Ger.,  GebJirmutter ;   It.,  matrice ;  Sp.,  matriz. 

Defixitox. — The  uterus  is  a  hollow,  thick-walled  organ,  shaped 
like  an  inverted  truncated  cone,  occupying  the  middle  of  the  pelvic 
ca\nty  between  the  bladder  and  rectum. 

PosiTiox. — The  normal  position  of  the  uterus  has  long  proved  a 
fruitful  subject  for  discussion  among  both  pure  anatomists  and  gyne- 
cologists. It  wall  be  impossible  to  rehearse  in  such  a  brief  paper  as 
this  the  results  of  the  many  investigations  that  have  been  made  in  order 
to  determine  a  point  ^vhich  at  the  first  glance  appears  so  simple.^ 

Much  of  the  difference  of  opinion  on  this  subject  has  arisen  from  the 
fact  that  observers  have  sought  to  assign  arbitrarily  a  certain  definite 
position  to  the  uterus,  and  have  not  made  due  allowance  for  the  influ- 
ences exerted  upon  it  by  neighboring  organs.     It  must  be  evident  to 

'  Compare  paper  by  Dr.  Mann  on  "Surgical  Operations  on  the  Pelvic  Organs  of 
Pregnant  Women,"   Gi/nnrrdoffiml  Transadion.",  vol.  vii. 

^  For  the  literatnre  of  the  snbject  the  reader  is  referred  to  Hart  and  Barbour's  Gj/nce- 
coJofpj,  chap,  ii.,  and  to  the  list  of  authors  appended  to  Ranney's  Topog.  Relations  of  the 
Female  Pelvic  Organs. 


132        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

any  one  who  has  studied  the  pelvic  organs  in  the  cadaver  that  no  dis- 
sections or  frozen  sections,  however  carefully  they  may  be  made,  can 
ever  present  a  perfect  picture  of  the  relation  of  these  organs  as  they 
appear  in  the  living  subject.  The  elasticity  of  the  tissues  is  lost,  and 
the  uterus,  deprived  of  its  natural  supports,  which  are  so  nicely  l^alanced 
during  life,  must  necessarily  assume  a  position  far  different  from  that 
which  it  once  occupied.  In  short,  such  results  as  those  obtained  by 
Schultze  and  Kohlrausch,  as  proved  by  their  figures,^  will  go  far  to  con- 
vince the  reader  that  clinical  observations  are  more  likely  to  give  a 
satisfactory  solution  of  this  question  than  are  pure  anatomical  studies. 
Still  more  reliable  are  those  results  which  are  obtained  by  a  judicious 
combination  of  both  methods.  It  is  sufficient  for  practical  purposes  to 
state  that,  with  the  bladder  and  rectum  empty,  the  uterus  is  normally  in 
a  position  of  slight  anteflexion,  the  os  externum  being  directed  down- 
ward and  backward,  and  the  entire  organ  having  an  inclination  toward 
the  right  side.^  To  what  extent  its  anterior  surface  is  in  contact  with 
the  posterior  aspect  of  the  bladder  (as  affirmed  by  Hart  and  Barbour) 
is  not  clear,  nor  is  it  of  any  practical  importance.  It  is  well  known 
that  the  uterus  possesses  a  considerable  range  of  mobility,  its  position 
varying  according  to  the  amount  of  distension  of  the  bladder.^ 

When  viewed  from  above  the  uterus  appears  as  a  pear-shaped  body, 
somewhat  flattened  from  before  backward,  so  that  its  anterior  surface 
is  nearly  plane,  the  posterior  being  distinctly  convex.  It  tapers  gradu- 
ally to  a  point  near  its  middle,  where  there  is  a  slight  depression  (most 
marked  on  the  posterior  aspect)  that  represents  the  line  of  demarkation 
between  the  body  and  the  cervix.  This  sulcus  is  not  seen  when  the 
uterus  is  observed  m  siht  in  the  living  body  or  when  it  is  injected  after 
its  removal.  The  fundus  uteri  lies  either  just  below  or  on  a  level  with 
the  plane  of  the  pelvic  brim  :  the  tip  of  the  cervix,  according  to  Savage, 
"  marks  nearly  the  centre  of  the  pelvic  cavity — the  centre  of  a  general 
radius  of  about  two  inches." 

Dimensions. — The  entire  length  of  the  unimpregnated  uterus  is 
about  three  inches,  the  cavity  of  the  organ  measuring  between  two  and 
two  and  a  half;  a  little  less  than  two  inches  belong  to  the  body.  The 
transverse  measurement  at  the  level  of  the  Fallopian  tubes  varies  from 
one  and  a  half  to  two  inches  ;  that  at  the  constricted  portion,  or  isthmus, 
from  one-half  to  one  inch.  The  average  antero-posterior  diameter  of 
the  organ  is  about  an  inch.  The  weight  of  the  virgin  uterus  varies 
from  seven  to  twelve  drachms.     The  sulcus  before  alluded  to  separates 

^  Hart  and  Barbour's  Gyncecology,  figs.  50,  51. 

^  There  is  doubtless  truth  in  Luschka's  idea,  that  muscular  fibres  in  the  utero-sacral 
ligaments  (called  by  him  the  retractores  uteri)  assist  by  their  contraction  in  maintain- 
ing the  uterus  in  a  position  of  anteversion  (Anatomic  der  WeibUchen  Beckens,  p.  361). 

•^  Compare  Van  de  Warker's  papers,  N.  Y.  Med.  Journ.^  vol.  xxi.  p.  337  ;  Am.  Journ. 
Obstetrics,  vol.  xi.  p.  314. 


tlic  iiicnis  into  two  jioitiofis — tlir  tipjx'r,  pyrifonn  mass  Itciiij:;  called  tlic 
l)o<lv  ;  the  lowci",  s|)iii(lli-.-li:i|»c(|  |)oitioii,  tlic  cervix.  Tliat  part  of  the 
l)o(|\'  wliicli  lies  alio\-e  a  line  joiiiiiiu'  llie  proximal  v\\d>  ol"tlie  I''alloj)iaii 
tiiUc-  is  known  as  the  fnndns.  The  cervix  has  been  thrther  snixlivided 
l)V  Sehroeder  into  three  se^nnents,  the  ni)per  and  lower  ol"  which  arc 
calletl,  iVoni  their  relation  to  the  point  ol"  attachment  of  the  fornix 
vaiiina',  the  supra-  and  inlravajiinal  portions,  while  an  intermediate 
zone  ol"  rather  indelinite  si/e  is  assnmed  as  existinj^  between  them. 
It  is  sullieient  for  practical  purposes  to  consider  the  cervix  as  con- 
sistintr  of  two  i)arts — an  nj)per,  which  lies  al)ove  the  va<;inal  vanlt, 
and  a  lower,  which  is  below  it.  The  snpravaginal  portion  of  the  cervix 
extends  from  the  istlunns  to  the  roof  of  the  vagina ;  its  transverse  diam- 
eter is  a  little  less  than  an  inch,  its  antero-posterior  half  as  great.  The 
relations  of  this  se<;;ment  of  the  uterns  are  important,  and  will  be 
described  later.  The  infra  vaginal  segment  of  the  cervix  is  most 
interestinii'  to  the  gynecologist,  because  it  is  the  only  jxirt  of  the  uterns 
which  is  directly  accessible  to  the  eye  and  finger.  Its  size  and  appear- 
ance are  extremely  variable,  according  to  the  age  and  sexual  activity  of 
the  subject.  In  the  virgin  the  cervix  appears  as  a  small  conical  projec- 
tion about  one-third  of  an  inch  in  length,  having  a  smooth,  firm  feel. 
Its  apex  measures  seven  or  eight  lines  transversely  and  five  in  its  ante- 
ro-posterior diameter.  At  its  centre  is  the  external  os  (os  tincae),  a 
small  opening  or  slit  one  or  tsvo  lines  in  width,  situated  between 
the  anterior  and  posterior  lips  and  directed  backward.  The  anterior 
lip  is  considerably  longer  than  the  posterior,  although  from  the  depth 
of  the  posterior  cul-de-sac  and  the  greater  distance  of  the  posterior  lip 
from  the  ostium  the  reverse  seems  to  the  true. 

The  cervix  in  nulliparous  married  women  is  usually  larger  than  in 
virgins ;  its  conical  shape  is  less  marked,  the  os  is  more  open,  and  the 
lips  have  a  softer  feel.  It  is  a  question  as  to  what  changes  may  occur 
in  the  cervix  within  strictly  normal  limits  as  the  result  of  parturition. 
In  multipara  the  lips  are  softened  and  increased  in  size,  and  the  os  is 
an  irregular  opening,  around  the  edges  of  which  are  small  irregularities 
and  cicatrices,  even  where  no  actual  laceration  has  occurred.  It  should 
not  be  forgotten  that  certain  pathological  conditions,  such  as  cervical 
endometritis,  may  lead  to  eversion  of  the  lips  and  an  irregular,  gaping 
OS — appearances  which  closely  simulate  the  results  of  childbearing. 
In  consequence  of  senile  atrophy  the  lips  may  become  so  shortened  that 
they  seem  to  be  almost  flush  with  the  vault  of  the  vagina. 

The  body  of  the  uterus  includes  that  portion  of  the  organ  which  lies 
above  the  isthmus.  Its  form  and  dimensions  have  already  been  referred 
to.  It  has  t^vo  surfaces  and  three  borders.  Of  the  former,  the  anterior 
surface  is  flattened,  the  ])osterior  convex.  The  upper  border,  which  is 
convex,  is  continuous  with  the  upper  surfaces  of  the  Fallopian  tubes. 


134        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

The  lateral  borders  are  convex  at  the  upper  portions^  but  become  con- 
cave at  the  isthmus.  At  the  superior  angles  of  the  uteriLS  (where  the 
lateral  pass  into  the  upper  border)  are  the  origins  of  the  tubes ;  just 
below  these  are  the  attachments  of  the  ovarian  ligaments,  while  still 
lower  the  round  ligaments  arise.  Besides  their  relations  to  these  struc- 
tures, the  lateral  borders  are  intimately  connected  with  the  broad  liga- 
ments, and  especially  with  the  vascular  plexuses  that  lie  bet^veen  their 
folds.  The  arteries,  veins,  and  lymphatics  enter  and  leave  the  uterus 
at  these  borders.  The  body  of  the  nulliparous  uterus  is  smaller  than 
that  of  the  multiparous,  and  is  more  distinctly  flattened  antero-poste- 
riorly,  while  the  triangular  outline  is  more  apparent. 

The  uterine  cavity  is  not  strictly  a  cavity  at  all  in  the  normal  organ, 
since  its  anterior  and  posterior  walls  are  in  contact.  As  studied  in  a 
coronal  section,  it  consists  of  two  portions,  between  which  is  a  constric- 
tion (the  isthmus).  The  cavity  of  the  body  has  a  triangular  shape,  the 
apex  of  the  triangle  being  at  the  isthmus,  while  at  each  end  of  the  base 
is  the  opening  of  a  Fallopian  tube.  A  third  opening  (os  internum) 
leads  from  the  cavity  of  the  uterus  into  that  of  the  cervix.  The  latter 
is  fusiform  before  childbirth,  conical  aftenvard ;  at  its  upper  end  is  the 
OS  internum,  while  the  os  externum  forms  its  lower  limit.  The  lenoth 
of  the  entire  uterine  cavit}'  averages  two  and  a  half  inches,  its  width 
one  and  a  half,  the  antero-posterior  diameter  of  the  corporeal  cavity 
nine-tenths  of  an  inch,  while  that  of  the  os  internum  is  three-eighths 
of  an  inch.  The  entire  capacity  of  the  uterine  cavity  is  tv\"0  or  three 
cubic  centimeters  (Sappey).  The  internal  lining  of  the  corporeal  cavity 
is  smooth,  that  of  the  cervix  is  corrugated.  As  in  the  vagina,  there  is 
a  longitudinal  ridge  on  both  the  anterior  and  posterior  walls,  from 
which  oblique  processes  (arbor  vitse  uterina)  are  given  off. 

AxATO]MY. — A.  Gross. — The  uterine  wall  consists  essentially  of  two 
layers,  the  muscular  strata  and  the  mucous  membrane.  The  peritoneal 
covering  of  the  organ,  although  intimately  connected  with  it,  is  not 
really  a  constituent  part  of  the  wall,  and  will  be  considered  Avith  the 
peritoneum.  The  muscular  tissue  of  the  uterus  is  best  developed  after 
impregnation,  when  it  may  be  separated  into  three  fairly  distinct  layers ; 
hence  a  minute  study  of  the  musculature  is  more  interesting  from  an 
obstetrical  than  from  a  gynecological  point  of  view.  Of  the  three 
layers,  the  external  or  superficial  is  most  distinct  over  the  anterior  and 
posterior  surfaces  of  the  organ,  where  it  is  seen  as  a  thin  layer  (closely 
adherent  to  the  peritoneum),  which  sends  off  prolongations  that  may  be 
traced  bet^veen  the  folds  of  the  broad  ligaments  (as  the  ovarian  liga- 
ments) and  along  the  round  ligaments  to  their  termination  in  the  mons 
"Veneris.     Both  of  these  ligaments  deserve  a  separate  description. 

The  former  fibres  are  derived  from  the  posterior  surface  of  the  uterus, 
the  latter  from  that  portion  of  the  "  j)latysma  "  (as  it  has  been  appro- 


UTERUS.  135 

priatcly  naninl)  wliidi  covits  its  anterior  siirracc.  The  siijH'rficial 
muscular  layor  oi'  the  Fallopian  tubus  is  als(j  derived  larj^-ely  Injui  tho 
latter  souree.  The  lateral  asjjeets  of  the  uterus  are  entirely  dev(jid  of 
this  sui)erli('ial  stratum.'  The  middle  layer,  which  is  hy  far  the  thick- 
est, consists  ol"  interlacing  fibres,  transverse  antl  longitudinal,  which  are 
coutimious  with  those  of  the  vagina,  having  a  similar  coiu-se.  Many 
of  the  longitudinal  fd)rcs,  however,  cannot  be  traced  beyond  the  cervix, 
wliere  thev  terminate  in  the  connective  tissue.  This  layer  constitutes 
the  principal  ])ortion  of  the  uterine  wall,  and  is  of  importance  beeause 
of  the  fact  that  it  contains  the  vessels.  These  are  enclosed  within  the 
network  of  libres,  and  may  be  studied  with  the  naked  eye  in  cross-sec- 
tions, their  intimate  relation  to  the  tissue  in  which  they  are  imbedded 
being  shown  by  the  fact  that  their  walls  do  not  collapse  Avheu  they  are 
divided  transversely. 

The  thin  nuiseular  fasciculi  of  the  internal  layer  have  a  general  cir- 
cular direction,  which  is  best  marked  around  the  os  internum,  where 
they  form  a  so-called  "sphincter."^  This  annular  arrangement  is  also 
seen  around  the  horns  of  the  uterus,  where  the  circular  fibres  are 
directly  continuous  with  those  of  the  Fallopian  tubes,  and  in  the  cer- 
vix at  the  point  of  attacliment  of  the  vagina.  Among  the  muscu- 
lar bundles  in  the  latter  situation  are  numerous  blood-vessels  and 
lym])h-si)aces,  that  run  transversely.  According  to  Chrobak,  the  cir- 
cular fibres  enter  the  mucous  layer,  so  that  the  union  between  the  two 
layers  is  an  intimate  one.^ 

The  connective  tissue  of  the  uterus  is  not  distributed  in  the  form  of 
definite  layers,  but  appears  as  irregular  masses  of  fibres  which  separate 
the  muscular  fasciculi  and  surround  the  vessels.  It  is  especially  rich 
ill  the  cervix,  as  will  be  inferred  from  its  extensive  hypertrophy  as  the 
result  of  pathological  conditions  (laceration).^  In  the  body  of  the 
organ  a  loose  areolar  tissue  is  present  in  considerable  quantity  in  the 
external  muscular  layer,  where  it  extends  longitudinally,  accompanying 
the  bundles  of  fibres.  In  the  middle  layer  the  individual  fibres  become 
finer,  while  their  distribution  is  circular ;  they  are  found  almost  exclu- 
sively around  the  vessels.     The  connective  tissue  of  the  inner  layer  is 

'  Vkk  Savage  {op.  cit.,  p.  47)  for  a  minute  description  of  the  external  layer,  which, 
togetiier  with  its  serous  covering,  he  denominates  the  "  sero-ihuscular  platysma."  He 
appears  to  regard  it  as  derived  almost  entirely  from  the  prolongations  of  the  longitu- 
dinal fibres  of  the  vaginal  wall,  which  simply  pass  over  the  surface  of  the  uterus  to  enter 
the  utero-sacral,  round,  and  broad  ligaments  and  the  Fallopian  tubes. 

'^  Helie,  Itecherches  sur  la  Di.^pos.  des  Fib.  muse,  de  I'  Utc'nt.%  Paris,  1869. 

^Savage  {op.  cit.,  p.  45)  is  almost  alone  in  his  positive  statement  that  "the  uterine 
walls  are  absolutely  inseparable  into  layers  or  coats,  and  no  sort  of  formula  of 
arrangement  of  fibre,  as  in  the  case  of  the  heart,  is  conceivable  in  respect  to  them." 
His  observations  must  have  been  confined  entirely  to  the  unimpreguated  organ. 

*Comp.  Wylie,  '"Observations  on  Laceration  of  the  Cervix  Uteri,"  Atn.  Jounu 
Obstetrici,  vol.  xv.,  No.  1,  Jan.,  1S82,  p.  20  (reprint). 


136        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


dlM^ 


/y/;c: 


'z^i^.m'i^'^i>- 


Section  of  the  Mucous  Membrane  of  the 
Uterus  from  near  the  Fundus  (Schafer) : 
a,  epithelium  of  inner  surface ;  6,  6',  ute- 
rine glands;  c,  interglandular  connective 
tissue  ;  d,  muscular  tissue. 


more  abundant  than  that  of  the 
median,  akhough  the  fibrillse  are 
so  delicate  that  they  are  not  readily- 
appreciable  with  the  naked  eye. 
There  is  still  some  difference  of 
opinion  among  anatomists  as  to 
whether  these  fibres  can  be  traced 
directly  into  the  mucous  membrane 
or  not.  We  have  not  the  space  in 
which  to  enter  upon  a  discussion  of 
this  question.  The  fact  that  there 
is  such  a  firm  attachment  of  the 
mucous  and  submucous  strata  to 
the  subjacent  parts,  aside  from  care- 
ful studies  of  the  normal  and  patho- 
logical histology  of  the  uterus,  leads 
the  writer  to  believe  that  both  the 
muscular  and  connective-tissue  fibres 
do  penetrate  the  mucous  membrane  ^ 
(Fig.  45). 

The  mucous  lining  of  the  uterine 
cavity  varies  in  thickness  from  half 
a  line  at  the  fundus  (or  less  in  the 
vicinity  of  the  cornua)  to  one-eighth 
or  one-quarter  of  the  entire  depth  of 
the  wall  near  the  centre  of  the  body. 
It  is  so  intimately  united  to  the  mus- 
cular tissue,  at  least  in  the  body  of 
the  organ,  that  the  existence  of  a  dis- 
tinct mucosa  has  long  been  denied  by 
many  competent  observers.  In  the 
cervical  cavity,  on  the  contrary, 
where  the  mucous  membrane  is 
much  thicker,  its  attachment  to  the 
muscle  is  not  so  firm,  a  layer  of 
areolar  tissue  intervening. 

On  account  of  the  marked  differ- 
ence between  the  mucosa  of  the  body 
and  that  of  the  cervix,  it  is  desirable 
that  they  should  be  considered  sepa- 
rately. That  of  the  body  is  smooth 
and  velvety,  of  a  grayish  or  grayish- 

1  Qnain's  Anal.  (9tli  ed.),  vol.  ii.,  fig.  610, 
p.  709. 


UTKRUS. 


1.^7 


rod  color,  mikI  ;iii  :i\('i:i^c  lliicUncss  oC  oiio-tAVOiity-fif'tli  of  an  iiidi. 
Tlicrc  is  a  coiiiiilctc  ahsciicc  of  folds  or  (•orrii<:;ations,  oxcopt  in  tlic; 
iimiu'diatc  viciiiily  ol"  the  (iil)al  oimI'iccs,  wlicrc  a  fow  Hiiiall  plica; 
inav  sometimes  he  distin^iiislicd,  according;-  to  Ilciiiiij^.  The  cervical 
mucous  mcmhraue,  as  was  pi'cvioiisly  statc<l,  dilVcrs  from  that  of  tlu; 
hodv  ill  hciii^'  disj)()seil  in  prominent  I'olds  or  rid<;-cs.  It  is  less  dis- 
tinctly red'  in  color,  and  is  thicker  and  firmer  to  the  touch.  Allusion 
has  heen  made  to  the  arranjijement  of  the  arhor  vitse  uterina  or  plicaj 
palmatjie.  (luyon  states  that  the  Ion»j;itudinal  rid<^cs  arc  not  exactly 
opposal,  but  that  the  anterior  one  fits  into  a  depression  in  the  posterior 
wall  of  the  cervix,  so  that  its  canal  is  practically  obliterated.  This  is 
best  marked  near  the  os  internum,  where  there  is  a  sharp  line  of  sep- 
aration between  the  nuicosie  of  the  cervix  and  body  (Fig.  46).     The 

Fui.  46. 


Interior  of  the  Cervix,  showing  the  arboreseent  appearanec  of  the  mucous  membrane 

'Playfair). 


arborescent  appearance  of  the  cervical  lining  membrane  is  best  observed 
in  a  virgin  uterus ;  after  parturition  it  becomes  less  distinct. 

B.  Minute. — In  a  section  including  the  entire  thickness  of  the  uterine 
wall  there  are  presented  fin-  study  several  distinct  varieties  of  tissues. 
It  is  well  to  caution  the  inexperienced  reader  that  many  of  the  familiar 
drawings  representing  the  histological  structure  of  the  uterus  are  largely 
diagrammatic,  having  been  constructed  by  the  comparison  of  a  number 
of  different  sections.     It  is  extremely  difficult  to  obtain  perfect  sections 

'  Yellnwisli-re^il.  acconlinii  to  iiidst  writers. 


138         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

of  the  mucous  membrane,  since  this  structure  is  very  delicate  and  soon 
becomes  disorganized.  The  writer  has  always  placed  more  confidence 
in  the  examination  of  fresh  scrapings  from  the  interior  of  the  uterus 
than  in  the  specimens  obtained  from  frozen  or  hardened  organs.  The 
peritoneal  covering  of  the  organ,  like  other  serous  membranes,  is 
most  intelligently  studied  by  staining  it  in  the  fresh  state. 

Proceeding  from  without  inward,  the  following  tissues  are  presented 
for  consideration :  (1)  A  delicate  serous  layer ;  (2)  a  dense  mass  of 
fibro-muscular  tissue,  in  which  are  three  different  varieties  of  fibres, 
blood-vessels,  and  lymphatics,  and  finally  numerous  nerve-filaments ; 
(3)  a  mucous  layer,  the  structure  of  which  differs  in  different  regions. 

(1)  The  relations  of  its  serous  covering  to  the  uterus  will  be  described 
in  the  paragraphs  on  the  pelvic  peritoneum :  it  is  sufficient  to  remind 
the  reader  that,  while  this  membrane  is  so  intimately  united  to  the 
muscular  tissue  over  the  anterior  and  upper  aspect  of  the  uterus  that  it 
can  hardly  be  separated  by  careful  dissection,  posteriorly  a  layer  of 
loose  areolar  tissue  is  interposed.  When  stained  with  nitrate  of  silver 
it  presents  the  ordinary  appearance  of  serous  surfaces — i.  e.  a  basis  of 
delicate  fibrous  and  elastic  tissue  supporting  large  endothelial  cells. 
The  capillary  and  lymphatic  plexuses  are  unusually  rich,  and  may  be 
traced  directly  into  those  of  the  muscular  wall ;  the  lymphatic  vessels 
are  provided  with  valves. 

(2)  The  distribution  of  the  muscular  substance  of  the  uterus  in  the 
fi^rm  of  strata  has  been  described.  Under  the  microscope  the  longitu- 
dinal fibres  will  be  identified  by  their  long  fusiform  cells  arranged  in 
parallel  rows.  In  the  centre  of  each  cell  is  a  large  oblong  nucleus 
that  takes  a  deeper  staining  than  the  surrounding  protoplasm.  The 
transverse  and  oblique  fasciculi  will  be  represented  by  round  or  oval 
bodies,  cross-sections  af  the  same  cells.  It  is  important  for  the 
beginner  to  become  perfectly  familiar  with  the  appearance  of  smooth 
muscular  fibres  in  whatever  plane  they  may  be  divided,  since  when 
stained  they  are  easily  mistaken  for  collections  of  leucocytes,  from  the 
presence  of  which  the  incautious  observer  might  infer  that  some  patho- 
logical condition  was  present.  It  should  be  remembered  that  the  fibre- 
cells  become  hypertrophied  during  pregnancy,  and  are  a  long  time  in 
returning  to  their  original  size.' 

Among  the  separate  fusiform  cells,  and  between  the  different  groups, 
there  will  be  seen,  in  addition  to  the  usual  structureless  cementing  sub- 
stance, numerous  fine  connective-tissue  fibres  :  if  the  latter  tissue  is 
treated  when  fresh  with  acetic  acid,  it  will  be  found  to  contain  a  con- 
siderable number  of  elastic  fibres.  These  are  recognized,  in  sections 
stained  with  carmine  or  hsematoxylin,  by  their  failure  to  retain  the  dye. 

^  Vide  Helie,  op.  cit. ;  also  Kreitzer,  St.  Petersb.  Med.  Zeitschrift,  1871,  Heft  ii. 
p.  113. 


VTERUS.  139 

111  tracint;  the  fihroiis  tissue  from  without  inward  it  will  he  scfii  that 
it  «;ra(hiallv  hccoincs  (iiicr  and  more  ('(tiidciiscd,  chaiiiiiiii;  its  direction 
tVoni  a  lou^iitudinal  couisc  in  thr  cxtcnial  muscular  hiycr  to  a  circular 
one  in  the  inner,  where  it  represents  at  some  points  the  so-ealled  *'siih- 
mueosa  "  o<"  mueoiis  memhraues.  In  the  median  layer  the  (ihres  inter- 
laee  in  a  eoiiiplieated  mauuei-  among  the  umstidar  huudles,  and  also 
aei'ompanv  the  blood-vessels,  which  they  surround  in  the  fnim  of 
riiii;s :  the  latter  arrangement  can  be  observed  in  u  eroti.s-seeti(jn  oi"  a 
nietl i  1 1  Ill-sized  artery. 

The  middle  musetilar  layer,  as  before  stated,  contains  a  large  jjart  of 
the  vessels  of  the  uterus.  The  arteries,  which  are  readily  recognized 
hy  their  thick  w^alls  and  convoluted  intima,  are  especially  abundant 
just  beneath  the  mucous  membrane,  wdiere  they  form  a  ca|)illary  net- 
work. The  veins  are  unusually  large  and  thin-walled,  and  are  with- 
out valves.  Their  walls  are  closely  adherent  to  the  surrounding  ves- 
sels, so  that  the  latter  remain  patulous  when  divided.  These  veins, 
wliicli  form  dense  plexuses  in  each  of  the  three  muscular  layers,  become 
.dilated  in  the  middle  layer  of  the  pregnant  uterus  to  form  irregular 
spaces  known  as  "sinuses."^  Rouget^  has  described  a  peculiar  mode 
of  communication  between  the  terminations  of  the  arteries  and  the 
veins,  in  which  the  former  are  connected  with  the  venous  sinuses  by 
means  of  minute  branches,  instead  of  by  tlie  usual  capillary  plexuses. 

The  lymphatics  contained  within  the  muscular  substance  of  the 
uterus  can  only  be  traced  by  means  of  special  injections.  Their 
extent  is  best  appreciated  in  pathological  preparations,  especially  in 
sections  of  interstitial  fibroids  that  are  undergoing  the  first  stage  of 
cyst-formation  ("  geodes  ").  In  addition  to  the  lymphatic  plexus  that 
was  mentioned  as  existing  just  beneath  the  serous  covering,  two  vari- 
eties of  lymphatics  may  be  demonstrated  within  the  muscular  sub- 
stance— a  vascular  netw^ork  which  accompanies  the  arteries,  and  a 
widespread  system  of  intercommunicating  spaces,  M'liich  not  only  fill 
the  intermuscular  connective  tissue,  but  surround  the  arteries  and  veins 
in  the  form  of  perivascular  sheaths.'^  According  to  Leopold,  these 
spaces  are  lined  by  a  single  layer  of  endothelium.  Tlie  writer  has 
never  been  so  fortunate  as  to  observe  this.  The  lymphatics  of  the 
muscular  and  serous  coats  (as  w^ell  as  of  those  of  the  mucous  mem- 
brane, to  be  mentioned  subsequently)  may  be  traced  to  large  vessels 
in  the  external  muscular  layer  that  empty  into  the  efferent  trunks  at 

'  Klein  {op.  cit.,  p.  268)  says  that  the  venous  sinuses  of  the  middle  stratum  rei)resent 
"  a  sort  of  cavernous  tissue." 

'^ "  Recherches  sur  les  Organes  erectile  de  la  Femme,"  Joum.  de  la  Phys.,  1858, 
p.  320. 

^  Comp.  Leopold's  exhaustive  article,  "  Die  Lymphgefasse  der  norraalar  nicbt 
Schwangern  Uterus,"  Arch.  f.  Gi/n.,  Bd.  vi.  lift.   1,   p.  ]. 


140        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

the  lateral  borders  of  the  uterus ;  the  latter  unite  with  the  lymphatics 
of  the  Fallopian  tube  and  ovary  and  terminate  in  the  lumbar  glands. 
The  minute  anatomy  of  the  nerves  of  the  uterus  has  been  most 
carefully  studied  by  Frankenhauser.  They  are  derived  from  the  sym- 
pathetic system,  and  their  fine  filaments  may  be  seen,  in  fortunate 
-p^^   ^„  preparations,  ramifying  among  the  muscular  bun- 

d  dies.     According  to  the  above  author,  they  termi- 

^^  '^  ^,,         nate  in  the  nuclei  of  the  fibre-cells. 

|>  ^  (3)  The  mucous  lining  of  the  body  of  the  uterus 

<^  "^    \s,  directly  continuous  with  the  internal  muscular 

jt  -     stratum,  the  usual  submucous  layer  being  w^ant- 

'•^1  ^    ing.     It  consists  of  a  loose  plexus  of  connective- 

rr^-'  ^    tissue  fibres,  among  which  may  be  seen  groups  of 

_r    fusiform  cells  that  are  derived  from  the  subjacent 
^    muscular  tissue.^     In  the  interstices  of  the  fibres 
^,     are  frequently  observed  collections  of  leucocytes : 
^     in  special  preparations  these  spaces  are  found  to 
-     be  lined  with  small  endothelial  cells,  each  of  which 
contains  an  oval  flattened  nucleus.^     From  its  his- 
tological appearance  the  mucosa  has  been  com- 
pared, not  inaptly,  to  the  "  stroma  of  lymphoid 
^r  organs."  ^     Leopold  *  calls  it  "  a  lymphatic  sur- 

^^  ^        face  which  contains  no  special  lymphatic  vessels, 

f^^-—    "^'=s?s^       |)ut  consists  of  lymph-sinuses  covered  with  en- 
utricuiar  Glands,  as  seen  in  dothclium."     The  free  surface  of  the  membrane 
IbepSd  of  commencing  i^  covcrcd  by  a  single  layer  of  columnar  epithelial 
pregnancy,  twice  the  nat-  cclls,  wliicli  are  SO  easily  detached  that  they  are 

ural     size,    shiowing    the        ,  ,  ...  .  -\      r^  i*        t 

arrangement   and  other  Seldom  sccu  m  S'ltu  in  scctions  made  Irom  hard- 
pecuiiarities  of  the  glands,   gned  Specimens.     The  presence  of  cilia  on  the  free 

a,  a,  a,  with  their  orifices,  ^  ^ 

a,  a,  a,  on  the  internal  sur-  surfacc  of  thcse  cells,  although  denied  by  a  few 
face  of  the  organ.  observers,Ms  well  established.^     The  writer  has 

found  them  in  fresh  scrapings  of  the  uterine  cavity,  removed  by  means 
of  the  curette,  although  they  were  never  in  motion  when  seen. 

The  mucous  membrane  is  filled  with  glands  (glandulse  uterinse)  of 
the  tubular  variety,  which  penetrate  through  its  entire  thickness,  their 

^  Savage  (Female  Pelvie  Organs,  Wood's  ed.,  p.  45)  says  that  the  tissue  composing  tlie 
framework  of  the  mucous  membrane  "  is  permeated  by  protoplasmic  amoeboid  mole- 
cules, which  by  cell-evolution  take  the  place  of  effete  fixed  cells,  amongst  others  the 
gland-cells,  which  are  dying  incessantly  in  the  act  of  giving  out  their  secretion."  This 
is  a  very  plausible  theory,  but  it  is  doubtful  if  it  rests  upon  any  positive  anatomical 
basis. 

^  Leopold,  quoted  by  Klein  {op.  ciL,  p.  266). 

^  Satterthwaite's  Manual  of  Histology,  p.  243.  ■*  Op.  cit,  p.  31. 

*  Garrigues,  De  Sin^ty. 

^  Strieker,  Die  Lehre  der  Geweben,  Leipzig,  1871,  p.  1173. 


UTKll  US. 


li 


ciils-dc-sac  occMsioiially  l)ciiiL;'  imlicdilrd  in  flic  iiiiicr  iiiusculiir  layer.  As 
'runu'i-  has  shown,  the  (lircctidii  ol"  the  inlands  is  not  perpendicular  to 
tlu'  surface  (as  lOnji'ehnaun  lij^ures  them'),  hut  is  nioi'e  or  less  ohli(juo.^ 
Thev  Miav  exist  as  single  tuhes,  sinuous  or  sj)iral,  hut  uiore  often  they 
<livide  into  t\\t>  or  three  hrauehes  near  their  lower  ends,  where  they 
hei'ouie  souiewhat  dilated.  In  htnjxitudiual  section  they  present  a 
delicate  hasenient  niend)rano,  which,  acc(jrding  to  Leopold,  is  "  coni- 
j)oscd  of  spindle-shaped  cells,  which  dovetail  into  one  another  like  the 
endothelium  of  the  cajjillaries  and  lymjihatics."''    The  existence  of  this 

¥\(i.   IS. 


Vertical  Section  through  the  Uterine  Mucous  Membrane  (Turner):  e,  columnar  epithelium; 
g,  g,  utricular  glands ;  ct,  connective  tissue  surrounding  glands ;  v,  v,  blood-vessels ;  mm, 
submucous  layer. 

merabrana  propria  in  the  iinimprcgnated  uterus  is  denied  bv  some 
authorities ;  others  state  that  it  is  only  found  near  the  orifice  of  the 
gland.  It  is  well  marked  in  the  pregnant  uterus.  Upon  this  mem- 
brane rests  a  single  layer  of  prismatic  cells,  with  single  large  nuclei 
near  their  bases.  It  is  now  generally  allowed  that  these  cells  are 
ciliated.^     The  uterine  glands  increase  largely  in  number  at  puberty, 

'  Am.  Joum,  of  Obstetrics,  vol.  viii.  p.  40. 

"^  Ranney,  Annals  of  Anat.  and  Surgery,  April,  1883.  rontra. 

^  Leopold,  quoted  by  Lusk  (op.  cit.,  p.  17).  See  also  Ercolani,  Utricular  Glands  of 
the  Ulcnis,  trans,  by  Marcy. 

*Comp.  Chrobak  in  Strieker's  Hnndbuch  ;  Nylander  {MiUler's  Archiv,  1852,  p.  375)  ; 
Lott  {Rolleifs  Unter.fuch..  Leipzig,  1871);  Willi.ims  (Structure  of  the  Mucous  Membrane 
of  the  Uterus)  ;  Friedliinder  (  Untersuch.  iiber  d.  U^lcru.%  1870). 


142        THE  ANATOMY  OF  THE  FEMALE  PELVIO  ORGANS. 

being  formed  by  a  simple  folcling-in  of  the  general  mucous  surface : 
during  menstruation  there  is  a  perceptible  increase  in  their  length, 
which  becomes  much  more  evident  during  pregnancy. 

The  mucous  membrane  possesses  its  own  vessels  and  nerves.  The 
glands  are  surrounded  with  rich  capillary  networks,  which  communi- 
cate with  the  plexuses  in  the  muscular  tissue ;  the  lymph-spaces  are 
directly  connected  with  the  lymph-sinuses  and  vessels  in  the  inner  layer. 
The  ultimate  ending  of  the  nerves  in  the  mucous  membrane  is  not  cer- 
tain. Some  of  them  enter  small  ganglia ;  others  form  plexuses  of  non- 
meduUated  fibres,  the  primitive  fibrils  of  which  are  seen  immediately 
below  (or  within?)  the  epithelial  cells.^ 

The  principal  diiferences  between  the  minute  anatomy  of  the  cervix 
and  that  of  the  body  of  the  uterus  lie  in  the  structure  of  the  mucous 
membrane.  There  is  no  serous  investment  to  the  cervix.  Its  infra- 
vaginal  portion  is  covered  externally  by  vaginal  mucous  membrane, 
the  appearance  of  which  under  the  microscope  has  already  been 
described.  A  section  through  the  muscular  substance  of  the  cervix 
shows  a  preponderance  of  firm  connective  tissue  as  compared  with  that 
in  the  body  of  the  organ.  The  muscular  interlacement  is  so  intricate 
that  a  separation  into  layers  is  not  possible.  "  In  the  cervix,"  says 
Savage,  "the  uterus  at  once  loses  the  characters  of  an  erectile  organ" — 
by  which  statement  he  evidently  refers  to  the  firmer  condition  of  the 
cervical  tissue  and  the  absence  of  the  large  venous  sinuses.  The  blood- 
vessels of  the  cervix  differ  from  those  of  the  body  in  possessing  small 
lumina  with  extremely  thick  walls,^  the  thickness  being  most  marked 
in  the  circular  layer  of  muscular  fibres.  Within  the  tissue  of  the  labia 
the  small  arteries  and  veins  run  in  parallel  rows  to  and  from  the  mucous 
membrane :  this  disposition  is  also  apparent  in  the  arbor  vitse,  where 
the  vessels  run  at  right  angles  to  the  free  surface. 

The  mucous  lining  to  the  cervical  cavity  is  considerably  thicker  than 
that  of  the  body.  In  a  cross-section  it  will  be  noted  that  there  is  a 
layer  of  connective  tissue  separating  the  epithelium  from  the  muscular 
coat.  The  parallel  rows  of  vessels  just  alluded  to  form  capillary  plex- 
uses beneath  the  epithelial  layer.  The  papillae  that  have  been  described 
by  so  many  writers,  and  in  which  the  capillaries  have  been  said  to  form 
loops,^  are  in  reality  appearances  presented  in  sections  that  have  been 
made  through  the  plica  palmatse.*  The  latter  are  due  simply  to  increase 
in  the  connective-tissue  framework. 

The  basis  of  the  cervical  mucosa  is  a  firm,  fibrous,  and  not  a  lym- 
phoid, tissue,  upon  which  rests  a  layer  of  ciliated  cylindrical  epithelial 

^  Lindgren.  quoted  by  Klein  (op.  cit,  p.  2fi8). 

^According  to  Henle  (Handbuch  der  Eingeweidelekre),  the  diameter  of  the  lumen 
averages  only  one-third  of  that  of  the  entire  vessel. 
=*  Lusk,  quoting  from  Henle  {op.  cU.,  p.  25).  *  Klein  {op.  at.,  p.  266). 


UTEIWS.  \V.\ 

colls.  Acconliiiti-  (<»  sonic  aiillinrilics,  llic  cilia  ari'  |(i(scii(  iinivcfsally 
over  the  ii[»|»cr  (\\(t-iliii-(ls  nl"  ihc  cervical  canal  ;'  the  most  rwciit  inves- 
tigations, however  (e>|tceially  those  ol'  I  )e  Sinety"j,  have  estal)lishe<l  the 
faet  that  eiliate<l  epithelinni  exists  throughout  tlu;  entire  cavity,  hut 
onl\-  u|)()n  the  suinniit  ot"  the  ridges,  the  colls  covering  the  depressions 
being  non-ciliated.^  The  glandular  structures  of  the  inend)ran(!  are  of 
the  rai'oniosc  varietv,  consisting  of  branching  ducts  with  dilate<I  ends. 
These  are  surrounded  by  capillary  plexuses,  and  consist  histologically 
of  simple  inversions  of  the  mucous  membrane.  They  are  line<l  by  a 
single  layer  of  non-ciliated  '  cid)ical  epithelium,  which  is  supported  by  a 
structureless  basement  membrane.  These  glands  open  upon  the  free 
surface  by  minute  apertures  that  are  both  upon  the  ridges  of  the  plica? 
and  in  the  depressions  between  them.  They  secrete  a  clear  mucus  hav- 
ing an  alkaline  reaction.  The  well-known  ovula  Nabothi  are  patho- 
logical appearances  due  to  the  occlusion  of  the  follicles  and  the  for- 
mation of  simple  retention-cysts. 

In  sections  of  the  cervix  at  the  level  of  the  os  externum  a  well- 
marked  line  of  separation  will  be  observed  between  the  ciliated  colum- 
nar epithelium  of  the  canal  and  the  vasculse  papillae  and  squamous  epi- 
thelium derived  from  the  reflexion  of  the  vaginal  mucous  membrane. 
The  latter  have  been  previously  described.  There  has  been  much  dis- 
cussion as  to  the  presence  or  absence  of  glands  on  the  vaginal  surface 
of  the  normal  cervix.  It  would  not  be  profitable  to  enlarge  upon  this 
topic  here.  The  writer's  observations  have  led  him  to  believe  that  De 
Sinety  and  Ruge  and  Veit  are  correct  in  denying  their  existence,  except 
under  pathological  conditions.^ 

Vessels  and  Nerves. — The  uterine  arteiy  is  a  most  important 
vessel  surgically.  It  arises  from  the  anterior  division  of  the  internal 
iliac,  and  takes  a  course  downward  and  inward  between  the  folds  of  the 
broad  ligament,  until  it  arrives  at  a  point  below  the  level  of  the  os  exter- 
num, just  above  the  lateral  fornix  of  the  vagina.  Here  it  makes  a  sharp 
turn  upward,  and  runs  along  the  lateral  border  of  the  uterus  to  unite 
at  about  the  centre  of  the  orQ-an  with  the  descendino-  branch  of  the 
ovarian  artery.  It  gives  off  numerous  horizontal  branches,  Avhich  run 
in  spirals  (hence  their  name,  "curling  arteries  of  the  uterus")  and  sup- 
ply the  various  segments  of  the  organ,  anastomosing  with  the  corre- 
sponding branches  of  the  opposite  vessel.  A  branch  of  considerable 
size  opposite  to  the  os  internum  unites  with  its  fellow  to  form  a  ring 

"  '  The  lower  limit  is  stated  by  some  as  within  one-sixth  of  an  inch  from  the  os 
externum. 

^  Also  Klein,  op.  dt.,  p.  266. 

'  In  children,  according  to  Lott  {Znr  Anat.  u.  Ph}/.<f.  der  Cenr'x  Uteri,  p.  17),  the  epi- 
thelium in  the  upper  half  of  the  cervix  is  not  ciliated. 

*  The  gland-cells  are  probably  ciliated  in  the  newborn,  but  not  after  puberty. 

*  See  Ruge  and  Veit,  Zur  Patholorjk  der  Va'jinalpordon,  Stuttgart,  1878. 


144        TEE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

around  the  cervix,  known  as  "the  circular  artery."  This  vessel  is  fre- 
quently found  at  a  lower  level.  Other  branches  run  over  the  fornix 
vaginee,  anastomosing  with  offsets  of  the  vaginal  artery.     The  latter 

Fig.  49. 


The  Ovarian,  Uterine,  and  Vaginal  Arteries  (Hyrtl) :  a,  ovarian  artery ;  a'  and  V,  branches  to 
tube ;  6,  branch  to  round  ligament ;  c,  uterine  artery ;  c',  branches  to  ovary ;  g,  vaginal 
artery ;  h,  azygos  artery  of  vagina. 

vessel  may  arise  directly  from  the  uterine.  AYilliams  has  called  par- 
ticular attention  to  the  fact  that  each  horizontal  segment  of  the  uterus 
has  to  some  extent  an  independent  vascular  supply,  so  that  flexions  of 


UTERUS. 


Ho 


the  oruaii   caimnt    roiilt    in   :iii\   Liiiicral  (»l)stru<'ti<>n  to  the  Mfxxl-flow. 
The  t'mulus  ivtvivcs  ;nMitinii;il   l)r:iiiclics  ihtm  tlii'  ovarian  arteries. 
TIk'  uttTUs  is  c'onipli'trly  >iiiroiin«l('(l   hy   intricate  vcnou.s  plexuses 


Vui.  .-,(1 


The  Nen-es  of  the  Uterus  (Fraukenhiiuser) :  A,  plexus  uterinus  magnus;  B,  plesrus  hypo- 
gastricuis;  1,  sacrum;  2,  rectum;  3,  bladder;  4,  uterus;  5,  ovary;  6,  fimbriated  extremity  of 
tube. 

(that  lie  beneath  tlie  peritoneum),  which  receive  the  blood  from  the 
veins  and  sinuses  within  the  walls  of  the  oro;an.  These  plexuses  com- 
municate freely  with  the  va_iz:inal  and  vesical  plexuses  below,  and  with  the 
pampiniform  above,  and  terminate  directly  in  the  internal  iliac  vein, 
indirectly  in  the  ovarian.  The  "  utero-vaujinal "  plexns,  as  fiirured  by 
Savage,  surrounds  the  lower  part  of  the  uterus  and  the  vaginal  fornix. 
The  ureters  run  directly  through  this  mass  of  veins  to  reach  the  bladder. 
The  lymphatics  coining  from  the  body  of  the  uterus  unite  on  each 

Vol.  I.— lu 


146 


THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


side  with  those  from  the  ovary  and  tube,  and  form  a  dense  network 
within  the  broad  ligament  around  the  pampiniform  plexus,  the  eiferent 
branches  of  which  ascend  in  company  with  the  ovarian  artery  and  ter- 
minate in  the  lumbar  glands.  The  lymphatics  from  the  cervix  and 
upper  extremity  of  the  vagina  form  a  plexus  at  the  level  of  the  os 
internum,  and  descend  on  each  side  to  the  base  of  the  broad  ligament, 
beneath  which  they  pass  to  enter  the  hypogastric  glands  around  the 
iliac  vessels :  here  they  are  joined  by  the  vesical  lymphatics.^ 

The  main  nerve-supply  of  the  uterus  is  derived  from  the  pelvic  or 
inferior  hypogastric  plexuses,  which  surround  the  rectum  and  send  fila- 
ments to  the  uterus  and  vagina.  These  are  prolongations  of  the  ute- 
rine plexus  that  lies  over  the  bifurcation  of  the  aorta.  The  uterine 
branches  spring  from  the  sides  of  the  pelvic  plexuses,  run  inward 
between  the  folds  of  the  broad  ligaments  until  they  reach  the  cervix, 
when  they  turn  upward,  accompanying  the  branches  of  the  uterine 
artery  and  entering  the  substance  of  the  organ  with  them.  A  large 
nervous  mass,  situated  bet^veen  the  cervix  and  rectum,  arises  from  the 

Fig.  51. 


Transverse  Section  of  the  Body,  showing  relations  of  fundus  uteri  (Savage) :  M,  pubes ;  A,  A, 
hypogastric  arteries  in  front,  spermatic  vessels  and  nerves  behind  ;  B,  bladder ;  L,  L,  round 
ligaments;  U,  fundus  uteri;  T,  T,  Fallopian  tubes;  0,0,  ovaries;  S,  rectum;  G,  right 
ureter ;  C,  utero-sacral  ligaments  ;   T',  last  lumbar  vertebra. 

union  of  branches  of  the  upper  sacral  nerves  and  ganglia,  and  a  num- 
ber of  sympathetic  twigs  from  the  hypogastric  plexus :  it  supplies  the 
cervix  chiefly,  and  is  enormously  enlarged  during  pregnancy. 

The   ultimate  termination    of  the   uterine   nerves    is  either  in  the 
nuclei  of  the  fibre-cells  or  in  submucous  g^anglia.^ 


^  Le  Bee  ("Contributions  a  I'Etude  des  Ligaments  larges,"  Gaz 
says  that  they  terminate  in  the  obturator  gland. 

^  Frankenhauser,  Hie  Nerven  der  Gebdnnutter,  etc.,  Jena,  1867. 


.,  Apr.  15, 1881) 


UTERUS.  I  17 

Relations  and  Connections. — Thoso  have  alnmly  Itccn  hkh- 
tioiu'd,  or  will  iu'  in  tho  course  of  the  .siux'xrdiii'r  pap'S.  For  con- 
vonioMcc  tlu'V  may  be  brieHy  rejieated.  As  has  been  statetl,  when  the 
bladder  and  rwtiim  are  empty  the  uterus  lies  normally  in  a  j)ositioii  of" 
sli«i:lit  anteHexion.  At  some  distanee  behnv  the  fundus  uteri,  and  sep- 
arated from  it  by  a  double  fold  of  peritoneum  and  a  (piantity  of  cellular 
tissue  (below  the  vesieo-uterine  pouch),  is  the  fundus  of  the  bladder. 
The  writer  cannot  accept  the  statement  that  the  fundus  rests  upon  the 
bladder,  as  tiijured  by  Schultze,  Pirogotf,  and  others.  Behind  the 
uterus  is  Doui][:las's  pouch,  which  separates  the  p<jsterior  a.spect  of  the 
ort^an  from  the  rectum.  When  the  bladder  is  empty,  coils  of  small 
intestine  till  the  upper  part  of  this  pouch  and  rest  against  the  fundus  and 
posterior  aspect  of  the  uterus.  Laterally  are  the  broad  ligaments,  in  the 
u])per  edges  of  which  are  the  Fallopian  tubes,  while  below  their  prox- 
imal extremities  are  the  origins  of  the  ovarian  and  round  ligaments. 
Below  is  the  vault  of  the  vagina,  which  surrounds  and  is  firmly 
attached  to  the  uterus.  Just  above  the  line  of  attachment  (utero- 
vaginal) is  the  portion  of  the  supravaginal  segment  of  the  cervix 
which  lies  in  the  subperitoneal  space  and  is  surrounded  by  areolar 
tissue  containing  venous  plexuses.  The  relations  of  the  pelvic  perito- 
neum and  connective  tissue  to  the  uterus  Avill  be  described  under  the 
subdivisions  which  treat  of  those  subjects.  The  so-called  false  and  true 
ligaments  of  the  uterus  (except  the  round  ligaments)  will  be  included 
under  the  same  topics. 

Practical  Deductions. — Allusion  has  been  made  to  the  range  of 
mobility  of  the  uterus  in  an  antero-posterior  plane.  It  is  important 
that  the  physician  should  learn  to  recognize  not  only  the  phvsiologi- 
cal  changes  of  position  produced  by  a  full  rectum  or  bladder,  but  those 
caused  by  posture.  For  example,  if  an  old  multipara  is  examined 
upon  the  back,  the  uterus,  by  reason  of  the  weight  of  the  organ  and 
the  relaxation  of  its  ligaments,  may  be  felt  through  the  posterior  fornix ; 
with  the  patient  semi-prone  the  uterus  falls  forward,  and  the  fimdus  is 
distinctly  touched  through  the  anterior  fornix.  Two  different  examiners 
may  thus  diagnosticate  ante-  and  retroversion  in  the  same  patient. 

The  normal  uterus  may  be  elevated  on  the  finger  to  the  extent  of 
between  one  and  two  inches  without  doing  injury  to  the  surrounding 
parts.*  The  reader  should  be  cautioned  against  accejiting  unhesitatingly 
the  statement  that  "  artificial  prolajysus "  is  an  entirely  harmless  pro- 
cedure. Experiments  made  upon  the  cadaver  are  not  conclusive ;  the 
inexperienced  will  ac-t  ^^^sely  in  distrusting  the  teaching  that  the  uterus 

'  A  clear  idea  of  the  mobility  of  the  uterus  in  a  vertical  direction  can  be  gained  by 
observing  (during  an  examination  with  the  speculum  i  the  manner  in  which  the  respi- 
ratory movements  are  transmitted  to  the  organ.  This  is  still  nn)re  marked  in  singing, 
defecation,  etc. 


148         THE  ANATOMY  OF  TEE  FEMALE  PELVIC  ORGANS. 

'■'■  can  be  drawn  downward  by  the  volsella  to  the  ostium  vaginae  without 
endangering  its  return  to  its  proper  position  in  the  pelvis  "  (Ranney). 
Practical  gynecologists  are  apt  to  be  cautious  in  resorting  to  such 
aids  to  diagnosis.  As  our  knowledge  of  the  frequency  of  tubal 
disease  and  localized  peritonitis  becomes  more  certain,  we  hesitate 
about  exerting  much  traction  upon  the  appendages  by  dragging  down 
the  uterus  in  the  manner  described.  It  is  necessar}^  to  be  on  one's 
guard  during  operations  or  examinations  under  ether,  because  when 
the  parts  are  thoroughly  relaxed  by  an  anaesthetic  a  uterus  which  pre- 
viously possessed  a  limited  range  of  mobility  can  be  pushed  upward 
or  depressed  to  an  extent  which  did  not  seem  possible.  IS^ot  having 
the  patient's  expressions  of  pain  as  an  index,  we  may  easily  rupture 
recent  peritonitic  adhesions  and  do  incalculable  harm  without  being 
aware  of  it.  The  cardinal  principle  in  gynecology  should  be  not  to 
do  the  woman  any  harm :  the  question  of  actually  benefiting  her  is 
often  of  secondary  importance.  The  reader  will  avoid  one,  by  no 
means  imaginary,  source  of  danger  if  he  learns  to  make  a  diagnosis 
and  to  practise  the  ordinary  operations  while  displacing  the  uterus  just 
as  little  as  possible,  either  with  or  without  instruments. 

While  we  become  familiar  with  the  normal  mobility  of  the  uterus, 
we  should  be  equally  prompt  to  recognize  impairment  of  the  same, 
either  partial  or  complete :  moreover,  if  this  information  can  be  gained 
without  the  use  of  the  sound,  so  much  the  better.  The  diagnosis  of 
retroflexion  with  fixation  Avill  be  discussed  elseAvhere. 

Ascension  of  the  uterus — a  normal  condition  in  pregnancy — should 
be  viewed  with  sus2:)icion  when  the  organ  is  not  thus  enlarged,  since  it 
points  to  the  probable  presence  of  adhesions  or  morbid  growths.  Xote 
that  it  does  not  follow  that  the  organ  is  thus  displaced  because  the 
examiner  finds  it  difficult  to  reach  the  cervix :  the  vagina  may  be 
unusually  long,  or  the  cervix  short.  By  examining  the  patient  upon 
the  side  the  mechanical  difficult}^  may  be  overcome.  The  extent  to 
which  the  uterus  can  be  elevated  is  best  appreciated  during  the  per- 
formance of  Alexander's  operation  :  the  limit  is  found  to  depend  not 
upon  the  mobility  of  the  organ,  l)ut  upon  the  length  of  cord  which 
can  be  drawn  through  the  inguinal  ring.  The  operator  can  hardly 
raise  the  uterus  too  high. 

As  the  uterus  is  capable  of  motion  laterally  as  w^ell  as  antero-poste- 
riorlv,  so  it  may  be  fixed  in  a  position  of  lateroflexion  by  cicatrices  in 
either  broad  ligament — a  displacement  which  it  is  particularly  difficult 
to  correct  by  means  of  tampons. 

Lateral  deviation  of  the  muciparous  uterus  is  frequently  observed 
when  the  patient  is  in  Sims's  position;  the  normal  mobilit}'  in  this 
direction  is  limited,  but  distinct.  Lateroflexion,  with  fixation,  it  is 
hardly  necessary  to  add,  is  a  more  serious  displacement,  pointing  to  a 


VTKIiVS.  1  JO 

f'oniici"  iiill;iiiiiii;itii>ii  in  niir  of  tlir  IhumiI  li;^;iiiu'iits  in  \vlii<li  the  corrf'- 
sjxhkIImj^  ovarv  ami  tiihc  arc  doiihtli'ss  iiivolvcd  ;  it  >li(nil«l  IcaW  the 
snpot'oii  to  be  on   his  ii;iiar<l  a<:;aiiist  any   ron<rli   inaiiipulalioiis. 

Tlio  (•haM«j:('s  ill  j)ositioii  consoijiU'iit  iijMtn  the  iiicn'asin<;  size  (»!"  tlic 
ortjaii  (prctiiiaiicy,  suliiiivnhition)  are  sclf-cvidciit :  the  tciidciicy  to  pro- 
lapsus ohservc'd  in  old  suhjcrts  is  often  exj)lained  by  j;eneral  atrophy 
and  loss  of  tone  in  its  supports,  the  or^an  itself  beinj;  really  of  small 
size.  It  is  only  necessary  to  allude  to  the  ])hysiolon;ical  changes  in  the 
shape  and  size  of  the  uterus.  It  is  not  always  an  easy  matter  to  recog- 
nize these  by  bimanual  paljjation  or  to  assign  them  to  their  proper  cause. 
The  diagnosis  of  early  pregnancy  from  the  sha})e  and  consistence  of  the 
organ,  as  suggested  by  Hegar,  deserves  the  careful  consideration  of 
every  gynecologist.  He  relies  upon  the  presence  of  softening  and 
thinning  of  the  inferior  segment  of  the  uterus,  as  well  as  the  pyramidal 
shape  assumed  by  the  body.'  There  is  a  peculiar  bulging  of  the  ante- 
rior Avail  and  an  elasticity  of  the  fundus,  as  felt  through  the  anterior 
fornix,  which  may  be  recognized  as  early  as  the  fifth  f»r  sixth  Aveek  of 
pregnancy,  even  when  the  cervix  docs  not  show  any  marked  changes. 

The  anatomy  of  the  cervix  uteri  and  its  surroundings  should 
be  carefully  studied  by  the  gynecologist.  He  who  forms  his  con- 
ception of  its  a})pcarance  entirely  from  descriptions  of  the  nulliparous 
cervix  will  be  sadly  puzzled  when  he  comes  to  touch,  or  to  observe 
through  the  speculum,  the  results  of  an  extensive  laceration.  It  is 
necessary  for  one  to  examine  a  large  number  of  multiparas  before  he 
can  be  in  a  position  to  appreciate  the  fact  that  no  two  cervices  are  alike. 
To  the  various  changes  in  shape,  size,  etc.  to  which  this  portion  of  the 
uterus  is  subject  as  the  result  of  pathological  conditions  (especially  lace- 
ration) we  need  not  refer,  since  these  are  touched  upon  elsewhere ;  the 
eifect  of  pregnancy  upon  the  size  and  consistence  of  the  part  is  described 
in  works  on  obstetrics.  It  was  stated  that  Schroeder's  division  of  the 
cervix  into  three  distinct  zones  is  more  or  less  artificial ;  the  "  portio 
intermedia  "  is  often  wanting  in  multipara.  In  old  subjects  the  cervix 
is  represented  by  a  small  nodule  projecting  from  the  vaginal  roof.  In 
cases  of  extensive  bilateral  laceration  with  e version  it  appears  to  be 
flush  with  the  roof,  until  the  opposite  lips  are  approximated,  according 
to  Emmet's  direction,  by  means  of  tenacula. 

The  long  axis  of  the  uterus  forms  such  an  angle  with  that  of  the 
vagina  that  the  reader  must  not  be  surprised  at  times  to  find  the  cer- 
vix high  up  against  the  posterior  fornix,  with  the  os  externum  resting 
against  the  rectum :  this  position  is  of  course  modified  as  the  rectum 
and  bladder  become  distended.  AVhen  the  vagina  is  unusually  deep 
and  the  cervix  long,  it  may  be  impossible  for  a  tyro  to  either  touch  the 
OS  or  to  bring  it  into  view  with  the  speculum.     By  applying  the  prin- 

^  Comp.  Prafjcr  Med.  Wochenschrij't,  "So.  26,  1884  ;  Annaies  de  Gynecologie,  Sept.,  1884. 


150        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

ciple  already  stated,  he  will  succeed  in  exposing  it  by  slipping  the  long- 
est blade  of  the  instrument  behind  the  cervix  and  gently  jurying  the 
latter  forward,  while  with  the  depressor  he  exerts  traction  upon  it  by 
making  pressure  in  the  anterior  fornix.  The  introduction  of  a  retro- 
version pessary  may  be  rendered  difficult  by  the  same  condition  of  the 
parts.  In  inserting  such  an  instrument  the  upper  bar  has  a  tendency 
to  slip  in  front  of  the  cervix  and  to  glide  into  the  anterior  cul-de-sac : 
when  this  occurs  the  beginner  should  remove  the  pessary  and  repeat 
the  manoeuvre,  instead  of  trying  to  carry  the  bar  backward  over  the  cer- 
vix into  position.  The  same  rule  should  be  followed  as  in  introducing 
the  speculum — i.  e.  to  hug  the  rectal  wall  closely  until  the  tip  of  the  cer- 
vix is  passed. 

A  few  brief  practical  points  may  be  mentioned  in  connection  with 
operations  on  the  cervix,  suggested  by  its  structure  and  relations.  The 
height  of  the  vaginal  attachment  varies ;  the  posterior  wall  of  the 
vagina  meets  the  cervix  at  a  point  above  the  junction  of  the  anterior. 
It  is  evident  that  a  laceration  of  the  cervix  through  the  vaginal  junc- 
tion must  be  an  extensive  one,  and  liable  to  be  followed  by  parametri- 
tis and  subsequent  cicatrization.  Amputation  of  an  hypertrophied  cer- 
vix may  be  compared  with  circumcision ;  if  the  uterus  is  drawn  down 
and  due  provision  is  not  made  for  the  retraction  of  the  vaginal  tissue, 
nearly  the  entire  fornix  may  be  excised,  leaving  an  unsightly  wound. 
In  high  amputation  for  cancer,  if  firm  traction  is  made  on  the  uterus 
while  the  vaginal  attachment  is  separated,  the  os  internum  will  be 
opposite  to  the  line  of  incision,  so  that  it  will  only  be  necessary  to 
divide  the  cervix  straight  across.  If  the  disease  has  invaded  the  body 
of  the  organ,  it  is  easy  to  remove  a  wedge-shaped  piece ;  when  the  parts 
are  allowed  to  retract,  the  operator  is  frequently  surprised  at  the  depth 
of  the  excavation. 

The  intimate  relation  of  the  cervix  to  the  broad  ligaments,  with  their 
labyrinth  of  blood-vessels  and  lymphatics,  renders  it  easy  for  us  to 
understand  the  reason  why  lacerations  may  be  followed  by  inflamma- 
tory processes.  The  frequency  of  so-called  cellulitis  has  been  ques- 
tioned, but  the  occurrence  of  inflammation  in  the  tissues  adjacent  to 
a  lacerated  cervix  as  the  result  of  septic  absortion  (whether  we  term  it 
lymphangitis,  periphlebitis,  or  cellulitis)  can  certainly  not  be  denied  in 
toto}  At  the  same  time,  the  direct  continuity  of  the  cervical  and  cor- 
poreal endometrium  points  to  a  certain  source  of  tubal  and  peritoneal 
trouble  originating  in  lesions  of  the  cervix.  In  all  of  the  autopsies 
performed  by  the  writer  in  fatal  cases  of  hystero-trachelorrhaphy  and 
posterior  section  (five  or  six)  death  was  due  to  an  extension  of  inflam- 
mation from  the  wound  iqncard  along  the  mucous  membrane,  not  out- 

^Comp.  paper  by  the  writer  in  Trans,  of  Alumni  Association  of  the  Woman's  Hospital, 
vol.  i.  p.  67. 


UTERUS.  \')\ 

tnird  iilniii;-  tlic  l)ii>;ii|  li^;^-:imriils.  Iiccalliiio-  (he  ;iii:iti)iiiy  <il"  lln-  utcro- 
sacnil  ligaments,  it  is  iiol  always  easy  tn  iiinlcr.-taml  liuw  |iararin'tritis 
postci'ioi-  can   be  a   tV('(|iiciit   acc()mj)aniiiicnt   <»1"  cci'vii-al    lesions. 

'I'liat  iiicisiuii  ol'  the  cci-vix  lor  stenosis  is  not  an  entirely  liarnilcss 
j)ro('etliire  is  e\i(lent  anatoniicallv  as  well  as  elinieally.  The  |)roximity 
of  tlie  peritoneum  and  the  rich  network  ol'  veins  which  lie  in  the  mns- 
cular  coat  ot"  the  ntei'us  render  the  daniicr  of"  |)eritonitis  and  septic 
ahsorplion  no  iniaiiinarv  one.  The  indications  are  clearly  to  make  the 
incision  as  liniiled  in  leiiLith  and  depth  as  j)ossil)l<',  and  to  ])ractise  i'i<;id 
antisepsis. 

The  corpus  uteri  is  only  indirectly  accessible  through  the  medium  of 
the  himanual  touch  ;  in  fat  subjects  it  is  frofjuontly  impossible  to  feel  it 
at  all.  Kxtreme  deviations  from  its  normal  size  and  ])ositioii  arc  easily 
recognized  by  the  most  inexperienced,  but  to  detect  moderate  enlarge- 
ments, small  fibroids  in  the  anterior  or  posterior  wall,  unusual  softness 
of  the  muscular  tissue,  etc.,  requires  long  practice  and  a  thorough  famil- 
iarity with  the  feel  of  the  normal  organ.  It  is  a  matter  of  daily  experi- 
ence among  laparotomists  to  find  on  opening  the  abdomen  that  the  size 
and  position  of  the  uterus  do  not  correspond  to  the  impressions  derived 
at  the  examining-table.  The  fundus,  as  touched  through  the  fornix, 
usually  appears  larger  than  it  really  is,  the  normal  protrusion  of  the 
anterior  surface  being  often  mistaken  for  an  interstitial  fibroid.  Some 
gynecologists  diagnosticate  anteflexion  whenever  they  feel  the  fundus 
uteri  through  the  anterior  fornix,  while  others  rarely  make  this  diag- 
nosis. If  the  reader  will  bear  in  mind  the  range  of  mobility  of  the 
organ,  he  will  doubtless  meet  with  fewer  displacements.  As  regards 
the  difference  between  anteversion  and  anteflexion,  the  reader  should 
remember  that  there  is  normally  a  distinct,  though  large,  angle  between 
the  cervix  and  the  body,  which  is  increased  when  the  uterus  is  enlarged 
and  of  softer  consistence  than  usual. 

It  does  not  belong  to  this  place  to  enter  at  length  into  a  consideration 
of  the  variations  in  the  shape  and  size  of  the  corpus  uteri.  The  possi- 
bility of  an  enlargement  being  due  to  pregnancy  should  always  be  kept 
in  view,  even  when  there  are  no  symptoms  pointing  to  that  condition, 
especially  when  an  operation  is  meditated.  In  the  absence  of  this  con- 
dition, it  will  remain  to  determine  whether  the  enlargement  is  general, 
and  is  caused  either  bv  some  growth  in  the  intra-uterine  eavitv  or  bv  a 
hypertrophy  of  the  muscular  substance,  or  is  of  an  irregular  character, 
due  to  growths  on  its  exterior.  Tiie  normal  changes  in  old  age — atrophy, 
decrease  in  depth,  etc. — must  not  be  mistaken  for  disease. 

Variations  in  the  consistency  of  the  uterine  wall  are  not  easily  recog- 
nized mdess  marked.  The  normal  fundus  has  a  Arm,  elastic  feel  as 
touched  through  the  fornix  ;  it  is  claimed  tliat  the  ]ieculiar  softness  of 
the  pregnant  organ  can  be  recognized  as  early  as  the  sixth  week.     In 


152        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

subinvolution,  in  malignant  disease  of  the  body,  etc.,  the  tissue  is  soft- 
ened. The  recognition  of  this  condition  of  the  muscle  should  lead 
the  surgeon  to  be  cautious  in  using  the  sound,  sharp  curette,  spoon- 
saw,  and  other  similar  instruments,  since  he  might  easily  perforate  the 
uterine  wall. 

There  are  many  points  in  regard  to  the  anatomy  of  the  uterus,  both 
gross  and  microscopic,  which  are  of  direct  surgical  interest.  The  depth 
of  the  cavity  in  the  unimpregnated  organ  is  usually  given  as  two  and  a 
half  inches,  but  it  frequently  exceeds  this  measurement  in  the  living 
female  by  reason  of  the  elasticity  of  the  wall.  Most  of  the  cases  in 
which  a  probe  is  supposed  to  enter  one  of  the  Fallopian  tubes,  because 
it  can  be  introduced  to  the  depth  of  four  or  five  inches,  should  be  viewed 
with  suspicion.  The  cavity  in  such  instances  is  doubtless  really  elon- 
gated ;  sometimes  the  wall  itself  is  perforated  without  serious  conse- 
quences, as  in  a  case  observed  by  the  writer.  It  is  important  for  the 
physician  to  become  thoroughly  familiar  with  the  depth,  direction,  and 
size  of  the  normal  cavity  as  indicated  by  the  probe  or  sound,  as  well 
as  with  the  peculiar  spongy,  elastic  sensation  communicated  through 
the  instrument  as  it  touches  the  fundal  mucous  membrane,  before  he 
can  expect  to  recognize  deviations  from  the  normal  at  the  examining- 
table  or  undertake  manipulations  within  the  cavity.  These  are  mat- 
ters not  of  description,  but  of  practice.  Beginners  invariably  forget 
that  the  uterine  canal  forms  a  decided  curve,  and  that  any  instrument 
designed  to  enter  it  must  either  have  a  corresponding  curve,  or  in  intro- 
ducing it  its  handle  must  be  carried  well  backward  to  a  line  parallel 
with  the  uterine  axis  ;  this  applies  particularly  to  tents.  A  glance  at 
a  median  section  of  the  pelvis  will  show  that  to  endeavor  to  push  a 
tent  straight  upward  in  the  axis  of  the  os  externum  is  to  lose  sight 
of  the  first  principles  of  common  sense,  still  more  those  of  anatomy ; 
in  fact,  the  writer  has  known  of  the  posterior  uterine  wall  being  per- 
forated in  this  way.  The  cavity  of  the  nulliparous  uterus  appears 
in  a  vertical  section  as  little  more  than  a  slit;  even  in  the  interior 
of  the  multiparous  organ  that  has  undergone  subinvolution  there  is 
scanty  room  for  manipulation  with  instruments.  Consequently,  in 
using  the  curette  we  are  limited  mainly  to  a  scraping  motion  in  a 
vertical  direction.  Considering  the  large  arc  described  with  the 
handle  of  a  sharp  curette  or  spoon-saw,  as  compared  with  the  small 
space  in  which  the  blade  revolves,  it  is  evident  that  some  care  must 
be  exercised  in  sweeping  the  latter  about  in  a  circular  direction. 

The  normal  constriction  at  the  os  internum  is  often  mistaken  for  a 
pathological  condition.  The  existence  of  an  angle  at  this  point  is  to  be 
remembered  in  introducing  the  sound,  which  is  often  arrested  at  this 
point  when  it  is  not  properly  curved ;  a  temporary  constriction  is  fre- 
quently caused  by  a  contraction  of  the  sphincter  muscle.     An  internal 


UTEIIVS.  lo,'] 

OS  wliirli  Icirclv  :i<liiiit>  nf  the  |»:i->;iLi«'  'it"  :i  jirolx'  will  ca.-ily  allnw  tin- 
iiiti'diliictiiiii  of  a  lai'iic  sniiiitl  wlicii  the  patient  i-.  aiia'.>tli('ti/f(l.  Another 
practical  hint  derived  Ironi  tlieaMi;le  l)et\veen  the  cervix  and  IxmIv  i.~  this: 
It" an  instrument  or  tent  i>  arrested  at  the  (ts  iiiterniiin,  draw  tiie  cervix 
downward  and  backward  with  a  tcnacidnni,  tliiis  rt'iideriiif^  the  canal 
more  neai'ly  straight. 

Our  opj)oi-tnnitii's  lor  stndyinj;' tiie  normal  liiiin;^  membrane  ot"  the 
utei  lis  are  few,  ondcwcopy  not  havin<^  achieved  many  satisfactory  results 
in  this  direction.  In  cases  of"  deep  laceration  of  the  cervix  with 
marked  eversion  the  nmeoiis  membrane  is  visible  nearly  as  high  up 
as  the  OS  internum,  but  its  angry,  florid  appearance  is  far  from  being 
that  of  health.  It  is  a  mistake  tosupj)ose  that  the  lining  of  the  corj)or- 
eal  cavity  luus  normally  a  s(jft,  spongy  feel ;  it  is  ratlier  elastic.  The 
rugae  in  the  cervical  canal  oflen  render  the  introduction  of  a  probe  dif- 
ficult when  a  sound  will  not  be  arrestcKl.  The  normal  endometrium 
being  poorly  sup})Iietl  with  sentient  nerves,  no  pain  should  be  experi- 
enced in  the  passage  of  an  instrument.  Extreme  sensitivenass  is  proof 
])()sitive  of  the  existence  of  disease.  The  uterine  wall  is  of  consider- 
able interest  surgically.  In  the  non-parous  organ,  when  removed  from 
the  body,  it  appears  to  be  semi-cartillaginons  and  almost  non-vascular, 
yet  few  structures  bleed  more  obstinately  when  wounded.  From  the 
thickness  of  the  wall,  as  seen  in  mesial  section,  as  well  as  from  its  inhe- 
rent toughness,  it  would  seem  as  if  a  blunt  instrament  could  not  be  forced 
through  it  except  by  the  exercise  of  great  violence ;  but  when  it  is  soft- 
ened by  pregnancy  or  disease  (subinvolution,  carcinoma)  the  accident 
might  easily  occur. 

Divulsion  of  the  cervix — a  procedure  which  is  frequently  practised  at 
the  present  day  to  the  exclusion  of  the  cutting  operation — owes  its  suc- 
cess to  the  complete  stretching,  or  even  tearing,  of  the  fibres  of  the 
sphincter  muscle.  Unless  this  is  thoroughly  effected,  the  benefit  will 
only  be  temporary.  In  incision  of  the  cervix  the  surgeon  aims  rather 
at  straightening,  than  at  enlarging,  the  canal.  The  idea  that  a  flexion 
can  be  ])ermanently  eliminated  by  the  use  of  an  intra-uterine  stem  is 
hardly  founded  on  anatomical   principles. 

Some  idea  of  the  extreme  vascularity  of  the  wall  will  be  gained 
during  operations  wliich  involve  direct  injury  to  it,  as  in  the  enuclea- 
tion of  interstitial  fibroids,  myomotomy  by  Schroeder's  method,  etc. ; 
fortunately,  the  contractility  of  the  muscular  substance  is  sufficient  to 
overcome  to  some  extent  the  tendency  to  bleeding.  Hemorrhage  from 
the  external  muscular  layer  is  difficult  to  control ;  the  peritoneal  covering 
of  the  uterus  is  sometimes  torn  while  separating  adherent  ovarian  tumors, 
when  the  venous  oozing  is  almost  uncontrollable.  Styptics,  the  actual 
cautery,  etc.  are  often  useless,  and  it  is  impossible  to  surround  the  bleed- 
ing points  with  ligatures.    During  an  ovariotomy  the  writer  was  obliged 


154        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

to  seize  the  bleeding  surfaces  en  masse  with  two  pairs  of  long  forceps, 
and  to  leave  these  in  the  abdomen  for  forty-eight  hours.  In  the  intra- 
peritoneal method  of  treating  the  stump  after  hysterectomy  it  is  import- 
ant to  secure  all  of  the  vessels  on  its  surface,  other^vise  a  dangerous 
oozing  may  occur  beneath  the  peritoneal  flaps. 

Although  the  peritoneal  covering  of  the  uterus  is  no  longer  regarded 
as  inviolable,  and  subserous  fibroids  are  now  removed  with  impunity,  it 
should  not  be  forgotten  that  this  covering  belongs  to  the  general  peri- 
toneal lining  of  the  pelvis,  in  which  inflammation  extends  rapidly.  The 
close  proximity  of  coils  of  small  intestine  to  the  uterus  favors  the  forma- 
tion of  adhesions  between  their  serous  surfaces  in  peritonitis.  If  the 
patient  recovers  with  permanent  adhesions,  she  will  be  subject  to  dis- 
tressing symptoms  referable  both  to  the  uterus  and  the  imprisoned  gut. 
Doubtless  this  complication  would  be  less  frequent  if  the  bowels  were 
moved  earlier  in  the  course  of  the  disease,  instead  of  being  paralyzed 
with  opium. 

The  minute  anatomy  of  the  uterus  does  not  concern  the  surgeon  so 
much  as  it  does  the  pathologist.  A  study  of  its  vast  network  of  veins 
and  lymphatics,  and  their  connection  with  the  mucous  membrane,  cannot 
fail  to  suggest  some  practical  lessons  in  regard  to  the  strict  use  of  anti- 
septics in  all  operations  within  the  cavity.  Although  this  article  does 
not  deal  with  obstetrics,  the  writer  cannot  avoid  the  temptation  to  reit- 
erate the  trite  maxim  that  an  intelligent  appreciation  of  the  absorbent 
power  of  the  uterine  vessels  would  lead  accoucheurs  to  view  with  appre- 
hension the  smallest  puerperal  lesion,  and  by  their  careful  use  of  anti- 
septics to  render  subsequent  attention  on  the  part  of  the  gynecologist 
unnecessar\\  The  normal  histology  'of"  the  cervix  possesses  no  small 
degree  of  practical  interest.  Attention  has  been  called  to  the  tran- 
sition from  the  columnar  epithelium  lining  the  cervical  canal  to  the 
squamous  variet}^  that  covers  the  portio  vaginalis  beyond  the  os  exter- 
num. The  importance  of  this  distinction  becomes  evident  in  study- 
ing the  pathology  of  cervical  ectropium  resulting  from  laceration. 
This  subject  is  discussed  elsewhere.  We  can  only  emphasize  here  the 
fact  that  "  ulceration  "  of  the  cervix  does  not  exist — that  the  raw  everted 
surface  seen  in  these  cases  is  really  "  a  neidy -formed  glandular  secret- 
inr/  surface  resembling  in  structure  the  cervical  mucous  membrane."  ^ 
The  importance  of  the  cervical  glands  in  this  connection,  as  well  as 
in  relation  to  the  development  of  epithelioma,  cannot  be  over-estimated. 
The  cervix  during  pregnancy  has  been  called  by  Fritsch  a  "  glandular 
organ,"  and  the  pathological  hypertrophy  of  the  glands  both  explains 
the  causation  of  cervical  catarrh  and  furnishes  a  hint  for  its  successftil 
treatment.  The  glands,  being  the  seat  of  the  disease,  must  be  thor- 
oughly destroyed  by  means  of  strong  caustics,  thorough  scraping  with 
'  Hart  and  Barbour,  op.  cit.,  p.  279. 


UTERUS.  \-)-) 

the  sluirp  curctto,  or  even   In'  coiiiplctt'  excision  (jf  the  iiiiicous  nioiu- 
brane  tu'c^orclinjr   to   Scliroecler's   iiu'tliod. 

The  cervix  is  coiiiposcd  essentially  of  connective  tissue,  wliich  is 
normally  toiii;h  and  resistant  ;  in  okl  a<:;e  it  may  assume  a  semi-carti- 
laginous consistence.  It  is  anatomically  and  clinically  one  of  tiie  least 
sensitive  ])ortions  of  the  genital  tract;  ojierations  have  frequently  been 
performed  uj)on  it  without  the  use  of  an  aniesthetic,  the  patient  experi- 
encing com})aratively  little  pain.  For  this  reason  it  is  difficult  to  esti- 
mate to  what  extent  cocaine  acts  as  a  local  anaesthetic  in  hystero-trach- 
elorrhaphy. 

This  portion  of  the  uterus  is  not  particularly  rich  in  nerve-filaments, 
nor  does  it  abound  in  those  terminal  i)ulbs  that  are  found  in  the  exter- 
nal genitals.  The  explanation  of  various  reflex  neuroses  in  cases  c^f 
lacerated  cervix  by  reference  to  the  inclusion  of  nerve-filaments  within 
the  "  cicatricial  plug "  at  the  angle  of  the  tear  does  not,  therefore, 
rest  on  a  positive  anatomical  basis. 

There  is  no  time  to  study  the  anatomy  of  the  uterus  \nt\\  reference 
to  the  origin  of  morbid  growths  from  its  tissues.  This  opens  up  an 
interesting  subject  which  has  been  fully  treated  by  Gusserow.' 

Some  familiarity  with  the  distribution  of  the  uterine  vessels  is  indis- 
pensable for  one  who  aspires  to  a  scientific  knowledge  of  gynecologv. 
Probably  not  one  medical  student  out  of  twenty  ever  takes  the  trouble 
to  inject  and  dissect  them  out  in  the  cadaver ;  fortunately,  a  study  of 
plates  and  museum-specimens  vnW  enable  him  to  sup])ly  his  deficient 
practical  knowledge  to  some  extent.  Writers  on  pelvic  pathologv  have 
unfortunately  shown  a  disposition  to  distort  anatomical  facts  to  suit 
their  individual  theories.  If  the  reader  will  glance  at  any  plate  show- 
ing the  pelvic  circulation  (Hyrtl's,  for  example),  he  will  recognize  the 
justness  of  Dr.  Williams's  criticism  of  the  theory  that  uterine 
"■  engorgement "  is  a  necessary  result  of  displacements,  especiallv 
flexions.  The  uterine  artery  gives  off  a  large  number  of  parallel 
branches  w^hich  run  at  right  angles  to  the  main  trunk,  and  anas- 
tomose freely  with  the  corresponding  branches  on  the  opposite  side, 
so  that  the  uteriLS  may  be  regarded  as  composed  of  numerous  seg- 
ments, each  of  w'hich  has  its  independent  vascular  supply.  It  is 
obvious,  without  argument,  that  no  flexion,  however  sharp,  can  cause 
any  considerable  interruption  of  the  circulation  either  above  or  below 
the  point  of  flexion.  The  same  principle  maybe  extended  to  supposed 
obstructions  in  the  periuterine  tissues  from  localized  inflammatorv  foci 
(peri-  or  parametritis) ;  the  pelvic  vessels  anastomose  too  freely  to  admit 
of  an  unquestioned  acceptance  of  the  theory  of  general  obstruction  and 
engorgement. 

The  uterine  vessels  are  of  importance  principally  from  a  surgical 
^  Nevbildungen  de.s  Z^tenui. 


156         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

standpoint.  In  vaginal  extirpation  of  the  uterus  it  is  important  to 
control  the  vessels  in  the  broad  ligaments  before  separating  the  uterine 
attachments.  Some  difficulty  may  be  experienced  in  passing  a  ligature 
around  the  ovarian  artery  from  below.  A  recent  writer  has  suggested 
that  the  operation  might  be  shortened  by  compressing  each  broad  liga- 
ment, with  its  contained  vessels,  with  a  pair  of  long  forceps,  detaching 
the  uterus,  and  afterward  securing  the  vessels  at  leisure.  There  is  some 
danger  in  this  method  that  one  or  more  of  them  may  slip,  when  it  will 
be  a  difficult  matter  to  pick  them  up  again.  The  defect  in  the  plan  of 
starving  a  malignant  growth  of  the  uterus  by  cutting  oflP  a  portion  of 
the  blood-supply  of  the  organ,  or  of  preventing  the  hemorrhage  in  sub- 
peritoneal myomotomy  by  ligating  one  or  two  of  the  arteries,  will  be 
evident  from  what  has  already  been  said  of  the  free  anastomosis  of  the 
pelvic  vessels.  It  should  be  noted  that  the  uterine  artery  runs  near  the 
base  of  the  broad  ligament,  so  that  its  pulsation  can  often  be  felt  through 
the  lateral  fornix.  Some  of  its  large  vaginal  branches  may  be  divided 
in  the  incision  for  gastro-elytrotomy.  The  circular  artery  of  the  cer- 
vix, formed  by  the  union  of  opposite  branches  from  the  main  trunks, 
is  a  bugbear  that  is  constantly  held  up  before  the  inexperienced  ope- 
rator. The  fact  is,  this  vessel,  which  lies  opposite  to  the  cervix,  is 
rarely  divided  in  Emmet's  operation,  and  when  it  is  the  hemorrhage 
can  be  readily  controlled  by  passing  a  wire  suture  beneath  it  and 
twisting  the  same.  In  cases  of  extensive  laceration  in  which  the 
denudation  is  carried  deep  into  the  angles  a  small  arterial  branch  is 
often  cut,  but  the  hemorrhage  is  by  no  means  as  alarming  as  we 
have  been  taught  to  expect. 

It  should  be  noted  that  in  certain  morbid  conditions  of  the  uterus 
(especially  fibro-cystic  disease)  the  vessels  are  enormously  enlarged,  so 
that  a  venous  hemorrhage  would  be  fatal  in  a  short  time. 

Our  knowledge  of  the  functional  nervous  affections  of  the  pelvic 
organs  is  as  fragmentary  as  the  study  of  their  nerve-distribution  is  dif- 
ficult. Pain  as  a  subjective  symptom  of  pelvic  disease  is  seldom  local- 
ized in  any  single  organ :  the  relation  between  the  plexuses  is  too  inti- 
mate to  admit  of  the  application  to  them  of  Hilton's  ingenious  theories. 
Doubtless,  many  supposed  ovarian  pains  are  really  due  to  disease  of 
the  uterus,  and  vice  versa.  When  we  advance  a  step  farther  and  con- 
sider the  relation  of  the  uterine  nerves  to  those  of  the  general  sympa- 
thetic system,  and  the  various  reflex  disturbances  which  result  from 
this  intercommunication,  we  begin  to  deal  with  psychical  phenomena 
which  have  little  to  do  Avith  the  sober  facts  of  pelvic  anatomy. 

We  cannot  conclude  these  rambling  remarks  on  uterine  surgery  more 
fitly  than  by  quoting  from  a  writer  of  the  old  school,  whose  caution  is 
too  often  disregarded  by  the  modern  gynecologist :  "  No  surgical  pro- 
ceeding whatever,  touching  any  part  of  the  uterine  system,  should  be 


ROUSl)    IJCAMKSTS.  Uu 

iniatt('ii(lc(l  l)y  the  ])i\'caiitioiis  ohscrvcd  in  operations  of  a  {rravc  dia- 
ractcr  (licrc  i»r  cIscwIktc  :  in  cri'tain  states  of"  the  }i;('n('ral  system,  unlore- 
sliadoweil  l»v  anv  recunni/.altle  peculiarity,  the  most  trivial  o|H'ration  has 
been  speedily  followed  by  i'atal  |)eritonitis."  ' 

The  round  lijiaments  are  pi'o|>erly  (leserii)e<l  in  couneetion  with  the 
uterus,  sinee  they  are  ically  otU^rowths  iVom  the  superficial  nuiseular 
hiyer. 

Round  Ligaments. 

Synonyms. — Susj)ensory  lijraments;  Lat.,  liframenta  rotunda,  lifra- 
menta  tereta  uteri;  Fr.,  litjaments  rouds  de  la  matrice;  GVr.,  runde 
ISIutterhander ;  //.,  Icgamenti  rotonde ;  8p.,  ligamentos  redondos. 

Definition. — The  round  litiaments  are  two  fibro-museular  cords 
which  spring  Injm  the  sujierior  angles  of  the  uterus,  extend  forward 
and  outward  to  the  internal  inguinal  ring,  and  pa.ss  through  the  inguinal 
canal  to  reach  the  anterior  aspect  of  the  symphysis  pubis,  where  they 
terminate  in  fibrous  expansions  which  are  lost  in  the  substance  of  the 
mons  Veneris. 

These  structures,  the  anatomy  of  which  is  commonly  dismissed  in 
a  few  words,  deserve  a  careful  description,  because  of  the  importance 
that  they  have  recently  assumed  in  connection  with  Alexander's  ope- 
ration. 

Each  ligament  appears  as  a  somewhat  flattened  cord,  which  remains 
of  quite  constant  size  in  the  same  subject  (and,  in  fact,  in  different 
subjects)  until  after  it  has  entered  the  inguinal  canal,  when  it  tapei*s 
gradually,  and  at  its  point  of  exit  varies  greatly  in  size  and  distinctness. 
Its  length  varies  from  four  to  five  inches.^ 

For  convenience  of  description,  the  ligament  may  be  divided  into 
three  portions — that  part  which  lies  within  the  pelvic  cavity,  that 
within  the  inguinal  canal,  and  the  terminal  portion.  The  pelvic 
division  of  the  ligament  is  attached  to  the  anterior  aspect  of  the 
upper  angle  of  tlie  uterus,  in  front  of,  and  imme<liately  below,  the 
origin  of  the  Fallopian  tube.  Lying  at  first  in  the  anterior  fold  of 
the  broad  ligament,  it  curves  upward  and  outward,  then  forward  and 
inward,  to  reach  the  internal  ring.  In  the  latter  part  of  its  course  it 
leaves  the  broad  ligament,  and,  enveloped  in  a  fold  of  peritoneum,  runs 
near  the  lateral  wall  of  the  pelvis,  lying  well  to  the  outer  side  of  tlie 
bladder  even  when  that  organ  is  distended ;  it  crosses  the  external 
iliac  and  obliterated  hypogastric  arteries,  and  at  the  internal  ring  has 
the  same  relations  as  the  spermatic  cord  in  the  male,  the  epigastric  artery 
curving  around  it  on  its  inner  side.     At  its  orijrin  the  lio;ament  is  larire 

'  Savage,  np  ciL,  p.  92. 

'-'  Madame  Boivin  has  stated  that  the  right  ligament  is  slightly  sliorter  and  tliicker 
tlian  tlie  left. 


158         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

and  fleshy,  and  has  a  somewhat  triangular  shape  on  cross-section ;  before 
leaving  the  broad  ligament  it  becomes  smaller  and  more  cylindrical. 
Within  the  inguinal  canal  (the  length  of  which  is  one  and  a  half 
inches)  it  is  nearly  round,  and  tapers  gradually  toward  the  external 
ring.  Its  relations  within  the  canal  are  identical  with  those  of  the 
spermatic  cord.  The  fold  of  peritoneum  that  envelops  the  intrapelvic 
portion  of  the  ligament  forms  a  slight  depression  at  the  internal  ring, 
but  does  not  usually  extend  beyond  this  point  in  the  adult,  although  in 
the  foetns  after  the  fifth  month  it  regularly  accompanies  the  ligament 
throughout  the  canal,  like  the  processus  vaginalis  in  the  male.     This 

Fig.  52. 


^M 


Horizontal  Section  of  Body,  showing  uterus  and  round  ligaments  (Savage):  B,  bladder;  U, 
uterus ;  C,  C,  utero-sacral  ligaments ;  L,  L,  round  ligaments :  0,  0,  ovaries ;  T,  T,  tubes ;  R, 
rectum. 


tube  of  peritoneum  is  occasionally  persistent  in  the  adult,  when  it  is 
known  as  the  canal  of  jN^uck.^ 

On  emerging  from  the  external  ring  the  ligament  lies  close  to  the 
outer  side  of  the  pubic  spine,  which  forms  the  surgical  guide  to  it  in 
Alexander's  operation.  On  reaching  the  anterior  aspect  of  the  sym- 
physis it  breaks  up  into  a  number  of  fine  strands,  which  are  lost  in  the 
fibrous  tissue  of  the  mons  and  upper  portion  of  the  corresponding  labium 
majus.  At  the  edge  of  the  ring  fibres  are  often  given  oif  which  are 
attached  to  surrounding  parts.  Three  sets  have  been  described  and 
figured — an  external,  an  internal,  and  a  median,  the  former  of  which 

^The  importance  of  tins  persistence  of  the  peritoneal  sheath  in  connection  with  the 
operation  of  shortening  the  round  ligaments  is  at  once  evident. 


J^ol'M)    Lie  AM  J:\TS. 


i:.:i 


l)l('ii(l  with  the  outer  pillar  <»!'  tlic  I'iiiji'  close  to  ( JiiiilKTiiat's  li;^aiiieiit  , 
the  lattei'  (eniiiiiate  in  ihi'  ii|)|>er  |)oi"tioii  olthe  external  i-iiiu",  wliile  th(- 
iiitenial  teniiiiial  lihi'cs  enter  (he  euiijoiiieil  temlon.  IJainey  '  in  liis 
(h'seription  of  the  i-onnd  lijianient  regards  1 1 lat  slrnetnre  as  l()i"ine(l  by 
till'  eoalesei'uee  of"  these   tlii'ei'  sets  oi'  libres.      It  seems  luore  correct  to 

Fig.  r,:i. 


\ 


u-- 


-4- 


Pubic  Termiiintinii  of  the  Round  Ligaments :  P,  pubis  where  covered  by  pubic  portion  of  apon- 
eurosis of  interior  (jblique  nmscle;  U,  fundus  uteri;  L,  uterine  extremity  of  round  liga- 
ment ;  JB,  aponeurosis  of  external  oblique  muscle ;  /,  internal  oblique  muscle ;  t,  transversalis 
muscle;  r,  rectus  muscle;  i\',  genital  brancli  of  genito-crural  nerve;  1.  external  terminating 
fibres  of  round  ligament  into  outer  pillar  uf  internal  ring  near  Gimbernat's  ligament ;  2, 
internal  terminating  fibres  into  conjoined  tendons  of  internal  oblique  muscle  and  transver- 
salis muscle,  near  pubis;  3,  middle  terminating  fibres  into  upper  part  of  external  ring;  4, 
internal  i)illar  of  external  ring;  5,  vessels  of  round  ligament,  nervous  filaments,  and  middle 
terminal  libres  of  round  ligament  descending  into  pudendal  sac.    (Savage.) 

reverse  this  order.  As  it  emerges  from  the  external  rino;  the  Umamentiim 
rotuiidiim  has  the  same  coverings  as  the  cord  in  the  male,  with  the 
exception  of  the  cremaster  muscle — viz.  the  integument,  superficial 
fascia,  intercolumnar  fliscia,  transversalis  fa.scia,  and,  lastly,  the  sub- 
peritoneal fat.  In  fat  subjects  the  areolar  tissue  around  the  ring  may 
be  so  loaded  with  adipose  that  it  is  difficult  to  distinguish  the  ligament ; 
moreover,  its  size,  color,  consistency,  strength,  the  point  at  which  it 
splits  up  into  its  terminal  fibres, — all  of  these  are  subject  to  normal 
variations,  as  the  writer  has  satisfied  himself  by  dissections  and  opera- 
tions on  the  cadaver. 

The  genital  l)raneh  of  the  genito-crural  nerve  lies  first  to  the  outer 
side,  and  then  in  front  of  the  ligament  on  its  emergence  from  the 
canal ;  a  little  lower  down  is  a  plexus  of  small  arteries  and  veins, 
among  Avhich  are  several  nerve-filaments.  The  va.scular  supply  of 
the  cord  is  derived  from  several  sources.     Near  the  uterus  it  receives 

'  "  On  the  Structure  and  Use  of  the  Ligamentiim  Hotundum  Uteri,"  London  Philo- 
soph.  Trans.,  1880,  p.  515. 


160        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

a  branch  from  the  ovarian  artery  that  enters  the  muscular  substance 
and  extends  in  it  along  the  inguinal  canal ;  at  the  internal  ring  it  has 
a  branch  from  the  deep  epigastric  which  supplies  the  exterior  of  the 
ligament  and  runs  upward  to  reach  the  uterus,  where  it  anastomoses 
with  a  branch  of  the  uterine  artery.  A  corresponding  vein  runs  with 
the  artery  (Fig.  42).  In  addition,  a  plexus  of  veins  from  the  pampini- 
form surrounds  the  pelvic  portion  of  the  ligament  and  sends  branches 
along  the  canal.  The  lymphatics  are  derived  from  the  uterine  plexuses : 
they  surround  the  cord  throughout  its  entire  extent  and  terminate  in  the 
superficial  inguinal  glands.  The  upper  portion  of  the  ligament  receives 
sympathetic  nerve-filaments  from  the  same  plexuses  that  supply  the 
muscular  substance  of  the  uterus,  while  the  genital  branch  of  the 
genito-crural  sends  filaments  to  its  terminal  portion. 

Steuctube. — The  basis  of  the  ligament  is  a  firm  fibrous  tissue 
which  we  may  trace  either  from  the  uterus  downward^  or  from  the 
mons  and  borders  of  the  external  ring  upward.  Xear  the  uterus  the 
ligament  has  a  well-marked  covering  of  smooth  muscular  tissue, 
derived  from  the  superficial  uterine  layer.  This  covering  persists  as 
far  as  the  internal  inguinal  ring,  beyond  which  point  it  is  not  easily 
distinguishable.  Rouget  claims  to  have  found  striated  muscular  fibres 
in  the  areolar  tissue  covering  the  lower  end  of.  the  ligament ;  he  says 
that  they  are  derived  from  the  transversalis  muscle.  Sappey  says  that 
"  striated  fibres  come  from  the  lower  part  of  the  inguinal  canal  and  from 
the  pubic  spine,  and  ascend  to  the  uterus,  but  generally  disappear  at  the 
level  of  the  superior  strait."  These,  he  affirms,  are  surrounded  by  the 
layer  of  smooth  muscle  derived  from  the  uterus,  "  like  the  sleeve  of  a 
coat."  The  peritoneal  envelope  of  the  ligament,  as  was  stated,  is 
usually  wanting  below  the  internal  ring. 

The  anatomy  of  these  cords  has  attracted  considerable  attention  in 
connection  with  Alexander's  operation.  They  are  more  developed  in 
multiparse,  as  they  increase  in  size  during  pregnancy  and  do  not  return 
to  their  original  size  after  delivery.  The  amount  of  "  slack  "  of  the 
ligament — if  it  may  be  so  expressed — allows  it  to  be  drawn  out  of  the 
external  ring  to  the  extent  of  three  or  four  inches.  The  relations  of 
the  intrapelvic  portion  of  the  ligament  to  the  peritoneum  are  import- 
ant ;  the  latter  envelops  the  cord  as  far  as  the  internal  ring,  or  forms 
a  sheath  for  it  throughout  the  canal  (as  the  canal  of  Xuck).  Fortu- 
nately, this  peritoneal  sheath  can  be  stripped  off  quite  readily  if  it  is 
drawn  throug'h  the  external  rino;  with  the  cord. 

The  appearance  of  the  round  ligament,  as  exposed  in  the  incision  for 
Alexander's  operation,  varies  greatly,  being  sometimes  a  prominent  red- 
dish cord,  at  others  a  bundle  of  indistinct,  scattered  fibres.  In  ver\'  fat 
subjects,  in  whom  the  external  ring  is  filled  with  a  mass  of  adipose 
tissue,  the  difficulty  is  obvious.     It  should  be  observ^ed  that  the  guide 


I'ALLoi'iAS  rrnics.  li;i 

to  tilt'  li^aiiicnt  is  tlic  (■xtciiiiil  riii^-,  wliidi  is  fiiiiiid  afcmdiii^-  to  tin- 
usual  uictliod,  tlu'  j)ul)ic  s|)iu('  scrviuji;  as  the  sur;j:ical  laudiuark.  Tlic 
l)lo(«l-V('ss('ls  wliicli  acconi|)auy  tlic  ('»)r(l  may  lead  to  its  idcntilic^ation 
in  caaes  of"  doubt. 


The  Uterine  Appendages. 

ITiidor  the  term  "uterine  a|)j)endau('s "  most  writers  include  both 
the  tubes  and  the  ovaries.  A\'e  shall  adopt  the  ordinary  .surjxical 
phraseology,  reminding  the  reader,  however,  that  the  relations  of  the 
two  organs  to  the  uterus  arc  essentially  diiferent.  The  tubes  are  the 
true  "  appi'udages,"  in  the  sense  that  they  are  originally  develojied 
from  the  uterus  and  represent  the  continuation  of  that  organ ;  the 
ovaries,  on  the  contrary,  are  developed  inde])endently  of  the  womb,  and 
have  no  direct  connection  with  it. 


Fallopian  Tubes. 

Synonyms. — Oviducts,  uterine  tubes ;  Gr.  uazspoad/.-r/yzz ;  Lat., 
tub?e  Fallopianoe,  oviductus  muliebres,  cornua  uteri,  vasa  dcferentia 
mulicris,  etc. ;  Fr.,  trompes  Fallopiennes,  on  uterines ;  Ger.,  Eileiter, 
Muttertrompete ;  It.,  trombe  di  Fallopio ;  Sp.,  trompas  dc  Falopio. 

Defixitiox. — Two  sinuous  tubes,  of  varying  dimensions,  which 
extend  outward  from  the  superior  angles  of  the  uterus  along  the  upper 
borders  of  the  broad  ligaments,  almost  to  the  edges  of  the  pelvic  brim. 

The  tubes  vary  in  length  from  three  to  five  inches,  the  right  being 
slightly  longer  than  the  left  and  lying  a  little  lower  in  the  pelvis. 
Their  general  direction  is  first  directly  outward,  then  backward  and 
inward,  so  that  each  tube  has  been  compared  to  a  shepherd's  crook. 
Three  portions  are  presented  for  study — the  isthmus,  ampulla,  and 
fimbriated  extremity.  The  isthmus  is  the  narrowest  ])art  of  the  tube, 
immediately  adjacent  to  the  uterus,  and  is  about  an  inch  in  length  ;  it 
extends  from  the  ostium  intermuu  through  the  uterine  wall  at  the 
cornu,  and  then  directly  outward  to  the  ampulla.  It  is  of  a  firm,  cord- 
like  consistency,  and  has  a  diameter  of  about  three  millimeters.  The 
lumen  is  extremely  small,  only  admitting  the  finest  bristle.  The  ampulla 
is  the  outer  dilated  portion  of  the  tube,  its  direction  being  outward,  then 
forward  and  downward.  The  diameter  varies  from  six  to  eight  milli- 
meters, while  the  lumen  expands  to  a  diameter  of  two  or  two  and  a 
half  millimeters.  The  fimbriated  extremity  (infundibukmi,  pavilion) 
is  a  funnel-shaped  expansion  surrounded  by  a  fringe  of  peculiar  fleshy 
processes  (fimbri;^),  which  recall  in  a  striking  manner  the  tentacles 
of  a  sea-anemone.  The  larger  processes  (four  or  five  in  number) 
are    known    as    "  primary "    fimbrife ;    others,    which    arise    from    the 

Vol.  I.— 11 


162        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

primary,  are  called  "secondary"  fimbriae,  and  vary  in  number  from 
eight  to  ten.  The  longest  of  the  former  lies  to  the  inner  side  of  the 
ostium,  and  is  attached  to  the  outer  end  of  the  ovary  (fimbria  ovarica). 
It  forms  a  groove  terminating  at  the  ostium.  A  small  fibrous  band, 
stretching  from  the  infundibulum  to  the  lateral  wall  of  the  pelvis,  i& 
known  as  the  infundibulo-pelvic  ligament. 

The  tube  has  two  openings — an  internal  or  uterine,  which  is  found 
at  the  superior  angle  of  the  uterine  cavity,  and  is  of  very  small  size ;: 
and  a  distal  opening,  the  ostium  abdominale,  already  described.  Quain 
states  that  "  a  second  smaller  fimbriated  opening  not  unfrequently 
occurs  at  a  short  distance  from  the  main  one."  ^ 

By  making  numerous  transverse  sections  of  the  tube  the  lumen  will 
be  seen  to  vary  in  diameter  at  different  points,  the  narrowest  part  being 
at,  or  near,  the  uterine  opening.  Remaining  of  nearly  constant  size  as 
far  as  the  middle  of  the  isthmus,  it  then  expands  suddenly  toward  the 
ampulla,  where  it  becomes  large  enough  to  admit  an  average  uterine 
sound.  The  distal  opening  is  only  apparently  larger  because  of  the 
distensibility  of  the  tube  at  this  point. 

Anatomy. — ^a.  Gi^oss. — The  tube  is  essentially  muscular  in  its 
structure,  resembling  closely  the  uterus,  from  which  it  is  an  out- 
growth. Beneath  the  serous  covering  is  an  outer  longitudinal  layer, 
derived  from  the  external  muscular  stratum  of  the  uterus,  and  an  inner 
layer  of  circular  fibres  which  forms  the  direct  continuation  of  the 
inner  uterine  layer.  Lining  the  interior  of  the  tube  is  a  thick  layer 
of  mucous  membrane,  which,  being  very  vascular,  is  normally  of  a 
rosy-red  (?)  color.  After  a  careful  examination  of  many  healthy 
and  diseased  tubes  immediately  after  their  removal,  with  a  view  ta 
determining  the  normal  appearance  of  their  lining  membrane,  the 
writer  has  come  to  the  conclusion  that  it  is  extremely  difficult  to 
decide  this  question.  In  every  case  in  which  a  ligature  is  placed 
around  the  proximal  end  of  the  tube  the  mucous  membrane  of  the 
excised  portion  beyond  the  ligature  is  so  congested  that  it  appears  of 
a  dark-red  or  bluish  color ;  the  same  hue  is  observed  in  the  tubes  of 
women  who  have  died  suddenly  during  menstruation.  On  the  other 
hand,  in  specimens  removed  from  the  cadaver  the  membrane  is  cer- 
tainly much  paler  than  it  is  during  life.  This  fact  is  of  importance 
in  connection  with  the  diagnosis  of  "  catarrhal  salpingitis,"  one  which 
is  frequently  made  at  the  present  day  by  laparotomists. 

The  membrane  is  disposed  in  the  isthmus  in  the  form  of  single 
longitudinal  folds,  which  in  the  ampulla  assume  a  more  complex 
structure  that  is  best  studied  in  a  cross-section  of  the  tube,  observed 
under  a  low  power  of  the  microscope.  Springing  from  the  primary 
rugse  are  numerous  secondary  and  tertiary  folds,  which  present  an 
1  Anatomy  (9th  ed.),  P-  713.     The  writer  has  never  observed  this  anomaly. 


FA  LI. on  A. \  rrni'js. 


163 


a|)|)<:ii;iiicr  aliiiost  idciit ir:il  with  that  of  a  scH-timi  made  tlii-(»ii;xl>  ''"' 
wall  t»t'  a  |)r(ilircratiii!j,-  ovarian  cyst,  ircmiiii^^  says  tiiat  lie  has 
CDuntcd  iVoin  thiVL-  to  li\<'  primary  I'olds  and  from  ei^ht  to  ten 
smaller  j)li<';e  "between  cadi  pair  of  the  foi'nici-."  This  statement  is 
somewhat  obscure,  but  the  aiithoi-  probably  means  that  these  smaller 
folds  sprin<i;  from  the  surface  of  tlie  uuicous  mend)i'ane,  and  not  from 

Fi(i.  54. 


Section  through  Ampulla  (Luschka),  under  low  power:  a,  submucous  layer;  b,  muscular  layer; 
c.  serous  coat ;  d,  mucous  membrane ;  e,  e,  vessels ;  1,  1,  small  xjriinary  folds ;  2,  2,  larger 
longitudinal  and  accessory  folds ;  3,  3.  small  folds  united,  forming  canaliculi. 

the  larger  projections.  There  are  no  rugae  in  the  intramural  tract  of 
the  tube.  The  dendritic  arraug-ement  becomes  less  marked  toward 
the  fimbriated  extremity,  where  the  longitudinal  folds  are  quite  dis- 
tinet  to  the  naked  eye. 

The  surface  of  the  mucosa  is  covered  normally  by  a  thin  layer  of 
grayish  mucus,  Avhich  has  a  distinct  alkaline  reaction.  The  variations 
in  the  amount,  color,  and  viscidity  of  this  mucus  cannot  be  definitely 
stated,  and  constantly  give  rise  to  loose  diagnoses  of  "  catarrhal  salpin- 
gitis." In  spite  of  Bandl's  assertion,  that  he  had  found  catarrh  of  the 
tubes  in  more  than  half  of  the  specimens  that  he  had  examined,  the 
writer  believes  that  one  is  unwarranted  in  assuming  the  presence  of  a 
pathological  condition  of  the  tubes  because  of  a  slight  congestion  and 
^  Krankheiten  der  Eileiter  und  die  Tubarschwangerschaft,  Stuttgart,  1876. 


164        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

increase  in  the  amount  of  mucus,  both  of  which  occurrences  are  nor- 
mal during  menstruation.  Certainly,  no  one  is  justified  in  making 
the  diagnosis  of  catarrhal  salpingitis  simply  from  a  gross  inspection 
of  the  organs.^ 

B.  Minute. — By  a  comparison  of  cross-sections  of  the  tube  made  at 
different  points  it  will  be  apparent  that  its  wall  is  not  of  the  same  thick- 
ness throughout.  The  serous  covering  extends  over  the  entire  tube, 
ceasing  at  the  ostium  abdominale,  where  it  is  directly  continuous  with 
the  mucous  lining  of  the  fimbrise ;  the  transition  from  the  flat  cells  of 
the  peritoneum  to  the  ciliated  columnar  epithelium  of  the  mucosa  is 
quite  abrupt.  The  peritoneal  covering  of  the  tube  is  strengthened  by 
an  increase  in  the  usual  amount  of  fibrous  and  elastic  tissue,  and  con- 
tains a  rich  capillary  network,  which  can  readily  be  demonstrated  with- 
out special  injections. 

The  muscular  coat  of  the  tube  is  much  thicker  in  the  proximal  than 
in  the  distal  half.  The  internal,  or  circular,  layer  is  especially  devel- 
oped at  the  uterine  opening,  Avhere  a  collection  of  fibres  has  been 
described  under  the  name  sphincter  tubse.^  In  a  cross-section  the 
outer  muscular  stratum  will  be  recognized  by  the  presence  of  the  divided 
spindle-cells,  the  inner  by  the  groups  of  cells  that  are  arranged  in  rows 
parallel  with  the  circumference  of  the  tube.  As  in  the  uterine  wall,  the 
circular  layer  contains  the  principal  vascular  plexuses ;  the  divided  ends 
of  the  arteries  and  the  large  gaping  veins,  surrounded  by  their  zones  of 
fibrous  and  muscular  tissue,  present  appearances  quite  similar  to  those 
in  the  uterus.  In  addition  to  the  smooth  muscle,  there  is  a  consider- 
able amount  of  connective  tissue  in  the  tubal  wall,  which  is  distrib- 
uted between  the  bundles  of  muscular  fibres  around  the  vessels  and 
beneath,  as  w^ell  as  in,  the  mucosa.  Klein  appears  to  regard  the  long- 
itudinal stratum  as  essentially  fibrous  in  character,  with  a  few  scat- 
tered bundles  of  smooth  muscles. 

The  mucous  membrane  of  the  tube  resembles  that  of  the  uterus  in 
possessing  no  well-marked  submucosa.  Its  relation  to  the  subjacent 
muscle  is  not  so  intimate  as  in  the  body  of  that  organ,  but  is  more 
like  that  of  the  cervical  canal.  Although  they  contain  a  considerable 
amount  of  fibrous  tissue,  the  plic£e  in  the  tube  are  not  so  essentially 
fibrous  in  their  structure  as  are  those  forming  the  arbor  vitae.  Under 
the  microscope  the  membrane  is  seen  to  be  covered  by  a  single  layer 
of  ciliated  columnar  cells,  beneath  which  are  two  or  three  supporting 
layers  of  cells  round  and  pyriform  in  shape.  The  cilia  are  best 
observed  in  fresh  scrapings  of  the  interior  of  the  tube.  They 
are  frequently  observed  moving  (although  slowly)  four  or  five 
hours  after  the  removal  of  the  tube  from  the  living  subject.  Their 
limited  vitality  in  these  cases  is  perhaps  due  to  the  effects  of  the 
1  Comp.  Bandl  [op.  ciL),  p.  8.  ^  Ibid.  {op.  dt),  p.  2. 


rALLoi'iAS  rrnKS.  lOo 

etlu'r-nart'osis,  -iiicc  that  (lni<:  is  well  kiidwii  to  Iw  liarnif'iil  to  tlu'tu.' 
The  |)i-t'S('iict'  ol'  its  intact  liiiiiijr  cjiitlicliiiiii,  and  tlic  )Ki*sist<'iH'('  an<l 
inotioii  (»r  tlu'  jH'i"islial>Ic  cilia,  arc  prool' |)(>>itivc  that  no  inflainniatory 
process  is  present  in  a  tiilic.  Moreover,  the  proj^cnoe  ol*  small  collec- 
tions ol"  nuicns-corpnscles  on  the  i'vw  siirlace  of  the  mucosa  d(x*s  not 
justitV  the  inference  that  :i  catarrhal  condition  is  present.  The 
mucous  menihrane  is  (piite  vascular.  Sections  through  the  plica? 
show  that  they  contain  loops  of"  vessels  as  well  as  large  lymj)h- 
spaces. 

The  arterial  su] »]ily  is  derive<l  from  the  spermatic  (ovarian)  arter}', 
the  distribution  <»f  the  branches  l)eing  as  follows  :  As  the  arterj'  enters 

Fig.  55. 


Section  of  the  Tube,  showing  Lymph-spaces  (Savage). 

the  broad  ligament,  it  gives  off  a  special  branch  to  the  fimbriated 
extremity  and  the  outer  end  of  the  ampulla  ;  from  the  ovarian  plexus 
several  small  twigs  run  to  the  middle  third  of  the  tube ;  while  the 
isthmus  receives  its  supply  by  branches  of  the  main  artery  and  that 
division  of  it  which  runs  to  the  fundus  uteri.  The  veins  of  the  tube 
enter  the  pampiniform  plexus.  The  lymphatics  unite  with  those  from 
the  ovar}'.  Xen'e-filaments  reach  the  tube  from  the  inferior  hypogastric 
plexuses  :  they  have  been  traced  into  the  mu.scular  tissue,  but  the  man- 
ner of  their  ultimate  termination  is  unknown. 

The  minute  anatomy  of  the  fimbriae  is  identical  with  that  of  the  rest 
of  the  tube,  and  does  not  require  a  separate  description.  The  peritoneal 
connections  of  the  tube  (mesosalpinx)  will  be  described  with  the  pelvic 
peritoneum. 

Practical  Deductioxs. — The  anatomical  relations  of  the  tube 
enable  us  to  explain  the  changes  which  take  place  as  the  result  of 
disea.se.  Lying  above  the  ovar}-  and  surrounding  it,  when  the  tube 
becomes  dilated  (as  in  hydro,  pyo-,  ha?matosalpinx,  or  tubal  preg- 
nancy), it  sinks,  together  with  the  former,  to  which  it  is  adherent,  to  a 
position  behind  and  near  the  base  of  the  broad  ligament,  where  the 

*  This  was  first  demonstrated  by  Lister  i  Laudois's  Manual  of  Human  PhysifAoyy,  trans. 
by  Stirling,  1885,  p.  614j. 


166        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

two  form  the  characteristic  sausage-shaped  mass  which  is  felt  through 
the  vaginal  fornix.  The  shape  of  this  body  and  its  position  at  the 
side  of  the  uterus  serve  to  distinguish  it  to  some  extent  from  a  pro- 
lapsed ovary.  The  proximity  of  the  small  intestine  explains  the  con- 
dition which  is  commonly  found  on  opening  the  abdomen  in  the  per- 
formance of  Tait's  operation,  the  tube,  ovary,  and  intestine  being 
matted  together  by  peritonitic  adhesions  firmly  attached  to  the  pos- 
terior surface  of  the  uterus  or  broad  ligament.  But  the  tube  may 
not  be  occluded ;  its  fimbriated  extremity  may  be  merely  agglutinated 
to  the  ovary  as  the  result  of  a  localized  peritonitis.  In  that  case  there 
will  be  no  displacement,  except  of  the  distal  extremity,  which  will  be 
drawn  inward.  The  relations  of  the  tube  to  the  ovary  are  not  altered 
even  when  the  latter  becomes  the  seat  of  cystic  degeneration.  As  is 
well  known,  the  tube  and  mesosalpinx  are  always  found  on  the  exte- 
rior of  the  cyst.  When  the  latter  is  intraligamentous — i.  e.  has  grown 
inward  between  the  folds  of  the  broad  ligament — the  tube  will  be 
closely  applied  to  the  surface  of  the  growth,  no  mesosalpinx  being 
present.  If  the  cyst  is  parovarian,  both  tube  and  ovary  will  be 
attached  to  the  cyst. 

The  tube  forms  the  principal  portion  of  the  pedicle,  which  is  tied 
before  the  removal  of  the  aj)pendages,  for  whatever  cause  the  operation 
may  be  performed,  hence  its  proximal  portion  possesses  no  little  inter- 
est for  the  laparotomist.  It  is  usually  tied  about  half  an  inch  from 
the  uterus.  There  is  no  advantage  in  ligating  closer  to  that  organ ;  in 
fact,  the  ligature  is  liable  to  slip  if  the  latter  course  is  adopted.  The 
needle  transfixes  the  mesosalpinx  midway  between  the  tube  and  the 
ovarian  ligament,  the  pedicle  being  tied  in  two  parts,  the  upper  con- 
sisting of  the  tube,  the  lower  of  the  ligament  and  the  ovarian 
vessels. 

The  continuity  of  the  mucous  lining  of  the  uterus  and  tubes,  and 
of  the  latter  with  the  peritoneum,  suggests  a  direct  channel  for  the 
transmission  of  septic  and  specific  infection,  to  which  it  is  only  neces- 
sary to  allude.  The  proximal  opening  of  the  tube  is  rarely  much 
dilated,  even  when  the  latter  is  greatly  distended.  Cases  are  on  record 
in  which  fluid  injected  into  the  uterus  was  supposed  to  have  passed 
through  the  tubes  and  into  the  peritoneal  cavity,  with  fatal  results. 
It  is  difficult  to  see  how  this  could  occur  during  the  use  of  a  vaginal 
injection ;  and  even  supposing  a  fluid  was  injected  into  the  uterine 
cavity,  and  its  exit  through  the  cervix  was  prevented,  it  would  require 
a  tremendous  pressure  to  force  it  through  the  minute  openings  of  the 
tubes.  In  order  to  be  on  the  safe  side,  the  reader  is  advised  to  inject 
fluids  into  the  uterus  only  when  he  is  sure  that  there  is  a  free  return- 
flow.  But  the  fear  of  an  accident,  which  is  certainly  exceedingly  rare, 
should  never  deter  us  from  the  judicious  use  of  intra-uterine  injections 


OVARIES.  1G7 

wlicii  tlic-c  ai'f  indicatcil.  ( 'ntlictcri/.iitioii  ;iii<l  cMiiIcri/atioii  of  llic  tiihcs, 
as  j)rn|»(>si'<l  l»v  Tyler  Smith  and  l''r(>ric|),  arc  dl"  course  of  no  practical 
value,  not  to  spcaU  of  the  (lilliciihy  and  danger  of  the  procedure. 

Tiic  auatoni\-  of  the  I'^illopian  liihes  is  not  iininiporlant  ])raclicall\'. 
The  muscular  coat  may  hecome  the  seat  ot"  hypci'trophy  (i'or  which 
condition  Munde  has  su;;i>;ested  the  term  "  pachysalj)in^itis "),  or  it 
may  i)e  u;rcatly  thimicd  when  the  tube  is  dilated  by  aoeumulatioiis  (»f 
lluid  or  the  urowth  of  a  misplaced  ovum.  Rupture  in  the  latter  case  is 
atti'uded  by  hemorrliai;e  irom  the  vessels  at  the  })lacental  site,  -which 
is   ofiten    i'atal. 

The  dominant  influence  over  menstruation  claimed  for  the  tubes  by 
Ml'.  Tait  gives  them  a  far  more  important  })osition  physiologically 
than  they  held  a  few  years  ago.  Their  highly  congested  appearance 
during  menstruation  (especially  marked  in  the  mucous  lining)  must 
not  be  mistaken  for  dlsca.se.  The  diagnosis  of  "catarrhal  salpingitis/' 
as  before  stated,  is  sometimes  made  on  insufficient  grounds,  since  the 
mucous  mendn'ane  is  normally  quite  vascular  and  is  covered  with  a 
layer  of  mucus.  If  moving  cilia  are  found  in  a  tube  soon  after  its 
removal,  there  can  be  no  extensive  inflammation  of  the  mucosa. 

Ovaries. 

Synonyms. —  Gr.  wdpioa',  Lett.,  ovaria,  testes  mnliebres ;  Fr., 
ovaires ;    Ger.,  Eierstocke ;    It.,  ovaje ;  Sj).,  ovarios. 

Definition. — The  ovaries  are  a  pair  of  small  oval  bodies  situated 
on  either  side  of  the  uterus,  in  the  posterior  folds  of  the  broad  liga- 
ments, below  the  distal  extremities  <tf  the  tubes.^ 

Position. — The  ovaries  are  situated  normally  either  inmiediately 
below  the  plane  of  the  pelvic  brim  or  partly  above  and  partlv  below.- 
The  true  position  of  the  vertical  axis  of  the  ovaiy  has  formed  the  sub- 
ject of  no  little  controversy.  Olshausen  maintains  that  it  extends  out- 
ward and  backward,  forming  with  the  transverse  axis  of  the  uterus  an 
angle  that  opens  backward.  Hasse,  on  the  contrary,  believes  that  the 
direction  of  the  axis  is  outward  and  forward.  Kolliker  describes  the 
axis  as  parallel  with  tlie  iliac  vessels,  and  figures  the  ovary  as  not  only 
occupying  an  oblique  position  with  regard  to  the  uterine  axis,  but  as 
being  also  tilted  in  such  a  manner  that  its  surfiices  look  inward  and 
outward  and  its  rounded  border  iipward  and  fonvard.  Scludtze  fig- 
ures the  ovarv  with  its  long  axis  at  right  angles  to  the  transverse  axis 

^  Small  accessory  ovaries  have  been  observed  bv  Hermann,  Beisl,  De  Sincty,  and 
othei-s.  These  are  probably  not  separate  organs,  but  rather  detached  portions  of 
•ovaries,  the  anomaly  bein.c:  explained  by  irregularities  of  development. 

-  One-half  of  the  ovary  is  above  the  plane  of  the  brim,  according  to  Hart  and 
Barbour. 


168         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

of  the  j)elvis,  while  His  even  insists  that  it  occupies  normally  a  vertical 
position,  its  rounded  border  looking  directly  backward.  The  writer 
has  never  been  able  to  satisfy  himself  that  the  normal  position  of  the 
organ  is  the  one  last  mentioned,  and  that  it  is  not  the  result  of  some 
previous  localized  inflammation  resulting  in  the  formation  of  slight 
adhesions,  such  as  are  more  often  present  than  absent  in  subjects  exam- 
ined at  the  autopsy-table.  In  fact,  it  is  hardly  possible  to  affirm  dog- 
matically that  a  certain  position  of  the  ovary  is  normal,  and  that  all 
other  positions  are  abnormal,  any  more  than  this  can  be  urged  of  the 
uterus.  The  ovaries  are  certainly  not  fixed  organs,  and  are  subject  to 
normal  variations  in  their  position,  although  within  circumscribed  limits. 
The  reader  may  content  himself  with  the  statement  that  the  axes  of  the 
organs  do  not  lie  exactly  in  the  transverse  axis  of  the  pelvis,  but  slightly 
oblique  to  it,  while  at  the  same  time  there  is  a  nutation,  or  inclination 
forward. 

Relations  and  Attachments. — The  ovary  may  be  regarded  as 
lying  in  the  plane  of  the  pelvic  brim.  It  is  described  by  Spencer 
Wells  as  situated  in  a  depression  in  the  posterior  fold  of  the  broad 
ligament ;  perhaps  it  would  be  more  correct  to  say  that  it  lies  in  front 
of  it,  being  attached  by  its  anterior  border  or  hilum  to  the  anterior 
fold.  In  front  is  the  anterior  fold  of  the  broad  ligament,  separated 
from  the  ovary,  except  at  the  hilum,  by  a  plexus  of  vessels  and  nerves. 
The  round  ligament  also  crosses  in  front  of  the  organ.  Above  and 
somewhat  in  front  is  the  Fallopian  tube,  separated  from  the  ovary  by 
the  mesosalpinx  above  and  by  the  parovarium  on  the  outer  side.  The 
tube  encircles  the  outer  extremity  of  the  organ,  so  that  the  fimbriated 
portion  finally  lies  below  the  convex  border.  The  left  ovary  is  in 
contact  with  coils  of  small  intestine  (at  least  when  the  bladder  is 
empty) ;  the  right  is  in  close  relation  to  the  rectum,  especially  when 
the  latter  is  distended.  The  inner  extremity  of  the  ovary  is  connected 
with  the  cornu  of  the  uterus  by  the  ovarian  ligament,  a  small  fibro- 
muscular  cord  about  an  inch  in  length,  which  springs  from  the  lateral 
border  of  the  uterus  immediately  below  the  origin  of  the  Fallopian 
tube,  and  receives  unstriped  muscular  fibres  from  the  external  laj-er  of 
the  uterus,  and  fibrous  tissue  from  the  tunica  albuginea  of  the  ovary. 
It  lies  in  the  posterior  fold  of  the  broad  ligament,  and  receives  a  com- 
plete peritoneal  investment.  Hart  and  Barbour  regard  it  as  simply  a 
"  longitudinal  fold  of  the  peritoneum,  into  which  the  unstriped  mus- 
cular fibre  of  the  uterus  is  prolonged."  The  upper  border  is  continu- 
ous externally  with  the  ovarian  fimbria  which  connects  the  ovary  with 
the  infundibulum.  The  lower  border  is  continuous  with  the  infun- 
dibulo-pelvic  ligament. 

The  ovary  is  usually  designated  as  an  oval  body.  It  is  more 
properly  described  as  a   ''flattened  ovoid,"   one-third   of  one  lateral 


OVMUKS.  !<;!> 

S^iiu'iit  <»t"  wliicli  i>  rcphifcd  hy  :i  >lr:iiL:lit  side  (S|)(ii(rr  Wells),  the 
l)rt)a(l,  roiiiidi'il  cikI  Ix'iiij:,-  dinctiMl  oiitwai'd,  w  Idle  tlic  siiiallcr,  j»(»iiitc<| 
t'Xtremity  oxtcud.s  toward  the  iitt'ius.  Both  tlic  antrridi-  and  j)(»tcri<jr 
.surfui-os  are  convex,  the  latter  beinj^  the  hroadci-  and  more  rounded  of 
the  two.  The  nru-au  is  siihject  to  many  variations  in  shape.  It  may 
he  tusitorm,  «i;lobnlar  (like  an  oI)I;it<'  spheroid),  di-f<»id.  or  dl"  a  --frictlv 
oval  form. 

The  size  varies  with  the  a«2;e  of  the  subject,  the  lunctional  a<tivity 
of  the  or«::an,  the;  <x-eurrence  of  menstruation,  pregnancy,  etc  Accord- 
injs:  to  Hennino;,  the  ovary  attains  its  largest  size  six  weeks  after  par- 
turition, when  its  ordinary  dimensions  (especially  its  length)  may  l>e 
doubled,  and  it  never  returns  to  its  original  size  after  involution.  After 
the  menopause  the  organ  shrinks  to  one-half,  or  one-third,  of  its  dimen- 
sions during  sexual  activity,  and  assumes  a  somewhat  fusiform  shape; 
The  average  measurements  given  by  Farrc  are :  Length,  1^  inches, 
width,  \%i\\^  of  an  inch,  thickness,  1  inch.  Luschka  states  that  the 
average  is :  Length,  4  centimeters,  width,  2.2  centimeters,  thickness, 
L3  centimeters.  The  weight  of  the  normal  ovar^^  varies  from  60  to 
135  grains,  the  average  weight  in  a  healthy  nullipara  being  87  grains. 

The  color  of  the  ovary  is  well  described  by  Tait  as  '^  a  pinkish, 
pearly  hue,  with  here  and  there  a  hazy  blueness  showing  through  the 
tissue,  when  a  follicle  is  either  getting  ready  for  the  discharge  of  its 
nucleas  or  is  disappearing  after  having  fulfilled  its  function."^  This 
description  applies  rather  to  the  quiescent  organ  in  the  virgin  or  young 
nullipara.  During  menstruation  it  appears  of  a  darker  hue,  w^hile  the 
ripe  Graafian  vesicles  assume  a  purple  color,  which  changes  to  a  dark- 
red  or  brown  after  the  discharge  of  their  contents ;  yellowish  spots  rep- 
resent so-called  corpora  lutea.  After  the  menopause  the  ovary  becomes 
of  a  whitish  color  and  almost  cartilaginous  consistence.  Before  puberty 
its  surface  is  uniformly  smooth,  but  as  menstruation  occurs  it  becomes 
covered  w'ith  depressions  and  cicatrices,  marking  the  sites  of  the  ruptured 
vesicles,  until  the  senile  organ  is  transformed  into  a  hard,  irregular  mass 
of  scars  and  nodules. 

Anatdmy. — A.  Gross. — In  approaching  this  subject,  it  may  be  well 
to  remind  the  reader  that  much  confusion  exists  at  the  present  time  with 
regard  to  Nvhat  constitutes  a  perfectly  normal  ovar}'.  Judged  by  the 
ordinary  standards  of  anatomical  normality,  such  an  organ  is  rarely 
found  either  in  the  dead-house  or  at  the  operating-table.  Even  when 
it  appears  on  gross  inspec-tion  to  offer  no  departure  from  the  normal, 
histologically  there  may  be  found  in  an  ovars'  changes  that  would  be 
regarded  as  j^athological  if  fi)nnd  in  other  organs.  On  the  other  hand, 
ovaries  that  are  apparently  the  seats  of  degenerative  changes  may  dis- 
charge their  functions  so  ]>erfectly  as  to  satisfv  the  demands  of  all  except 

'  Discfises  of  the  Ovaries  (4th  ed.),  p.  5. 


170        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

the  ardent  laparotomist.  In  other  words,  the  boundary  between  the 
normal  and  pathological  is  not  a  fixed  one,  and  in  spite  of  numerous 
careful  studies  of  the  subject  there  yet  remain  many  mooted  jDoints. 
Many  of  the  classical  drawings  that  have  been  copied  by  several  gen- 
erations of  writers  are  largely  diagrammatic,  having  been  constructed 
as  the  result  of  careful  comparisons  instituted  between  sections  of  the 
human  ovary  and  those  of  the  lower  animals,  especially  the  cat.  This 
caution  may  serve  to  soften  the  disappointment  experienced  by  the 
student  after  his  repeated  failures  to  hit  upon  sections  that  correspond 
exactly  with  the  familiar  illustrations  of  the  textbooks.  The  micro- 
scopist  who  succeeds  in  determining  to  what  extent  an  ovary  may  con- 
tain cysts  without  being  "  cystic,"  and  just  how  much  fibrous  tissue 
must  exist  in  its  stroma  before  the  diagnosis  of  "  cirrhosis  "  is  justi- 
ciable, will  deserve  no  little  praise. 

In  describing  an  ovary  we  may  consider  its  extremities,  borders,  and 
surfaces, -two  of  each.  The  inner  extremity,  which  is  distant  about  an 
inch  from  the  uterus,  is  long  and  pointed,  and  tapers  gradually  into  the 
ovarian  ligament.  The  outer  is  thickened  and  rounded,  and  is  situated 
more  posterior,  with  reference  to  the  transverse  axis  of  the  pelvis,  than 
the  inner ;  to  it  is  attached  the  fimbria  ovarica  before  mentioned,  which 
is  sometimes  regarded  as  one  of  the  ovarian  ligaments. 

The  borders  of  the  ovary  are  designated  "  upper  "  and  "  lower,"  and 
its  surfaces  "anterior"  and  "posterior."  Considering  the  true  position 
of  the  organ,  it  is  more  correct  to  reverse  the  terms,  the  surfaces  being 
termed  upper  and  lower.  The  posterior  border  is  convex,  and  is  free, 
or  not  covered  by  peritoneum ;  the  anterior  is  straight,  somewhat  flat- 
tened, and  is  attached  to  the  posterior  fold  of  the  broad  ligament.  It  is 
known  as  the  hilum,  and  is  the  portal  through  which  the  vessels  and 
nerves  of  the  organ  enter.  The  superior  surface  is  nearly  flat,  and 
looks  upward  and  forsvard,  while  the  posterior  is  decidedly  convex 
and  is  directed  downward  and  backward. 

On  making  a  longitudinal  section  of  an  ovary  from  a  healthy  adult 
there  will  be  presented  two  zones  of  tissue — a  central  and  a  peripheral. 
The  former  has  a  jjinkish-gray  or  even  rosy  hue,  is  of  soft  consistence, 
and  has  a  moist,  glistening  appearance.  The  peripheral  zone  is  white 
or  grayish-Avhite,  and  has  a  firm,  semi-cartilaginous  (or,  more  properly, 
ligamentous)  structure.  The  former  is  evidently  well  supplied  with 
vessels,  especially  near  its  margin,  while  the  latter  seems  to  be  non- 
vascular. A  closer  examination  of  the  cut  surface  will  reveal  the 
presence  of  numbers  of  small  pits  and  vesicles  of  variable  size,  those 
near  the  periphery  being  the  smallest  as  well  as  the  most  numerous ; 
imbedded  in  the  central  portion  of  the  surface  are  several  of  these 
cystic  bodies  of  much  larger  size,  while  in  the  peripheral  zone  are  a 
few  vesicles,  the  size  of  small  peas,  which  are  filled  with  clear  fluid. 


OVMllES. 


171 


The  latter  hodics  piMJcct  iiutrc  (ir  less  :il)ov('  the  lire  stirfiuT  of  tli<" 
ovary,  and  (Hic  oi-  two  of  tliciii  will  f^cnerally  l)e  ho  (liHtcnd('<I  with 
lluid  and  tliiii  walls  tliat  tlicy  rnptun'  on  tlio  application  of  sli;;lit 
pre.ssurc.  In  tlio  }K'riplu'rv  will  also  he  seen  the  remains  of"  rnj)tnre<l 
ovisacs  in  all  stages  of  retrogiiule  metamorphosis,  from  a  hlood-clot 
to  a  firm,  hloodloss  cicatrix.  The  general  disposition  of  the  hands  (»f 
fibrous  tissue  in  the  stroma  are  also  evident  to  the  naked  eve,  although 


Fig.  56. 


Section  of  the  Ovaiy  of  an  Adult  Bitch  :  a,  germ-epithelium ;  h,  egg-tubes  ;  c,  c,  small  follicles ; 
d,  more  advanced  follicles;  e,  discus  proligerus  and  ovum;  /,  second  ovum  in  the  same 
follicle  (this  occurs  but  rarely; ;  g,  outer  tunic  of  the  follicle  ;  h,  inner  tunic;  i,  membrana 
granulosa ;  k,  collapsed  retrograded  follicle  ;  I,  blood-vessels  ;  m,  m,  longitudinal  and  trans- 
verse sections  of  tubes  of  the  parovarium;  y,  involuted  portion  of  the  gcrm-cpithelium 
of  the  surface ;  z,  place  of  the  transition  from  peritoneal  to  germinal  or  ovarian  epithelium- 
(Waldeyer.) 

the  more  complex  interlacement  i.?  only  apparent  under  the  microscope. 
These  fibres  not  only  radiate  in  all  directions  from  the  hilus,  hut  also 
surround  the  ovisacs  and  vessels.  The  vascular  richness  of  the  organ 
is   best   appreciated   in  injected  specimens,  but  the   divided  ends  of 


172        THE  ANATOMY  OF  THE   FEMALE  PELVIC  ORGANS. 

numerous  arteries  will  be  seen  on  the  cut  surface  of  the  ovary  even 
in  its  natural  state. 

B.  Minute. — The  microscopical  anatomy  is  so  important  that  the 
writer  feels  justified  in  devoting  to  it  what  may  seem  like  a  dis- 
proportionate amount  of  the  limited  space  at  his  disposal. 

Three  points  are  presented  for  study — the  exterior  of  the  ovaiy,  the 
fibrous  (or  fibro-muscular)  tissue,  and  the  Graafian  vesicles.  The  exter- 
nal covering  is  best  observed  in  fresh  preparations  that  have  been 
specially  stained.  Contrary  to  the  opinion  of  Waldeyer,  Leopold, 
Klein,  and  many  other  microscopists  Avho  have  carefully  investiga- 
ted the  matter,  Mr,  Tait  confidently  affirms  that  "  the  posterior  sur- 
face, when  treated  by  silver  and  other  staining  methods,  displays 
the  same  stomata  and  stigmata  as  does  the  anterior  surface" — in 
short,  that  the  ovary  is  entirely  covered  by  a  layer  of  peritoneum, 
the  presence  of  which  on  the  posterior  surface  can  be  recognized  by 
finding  the  scpiamous  epithelium  which  is  characteristic  of  that 
membrane.^ 

Without  entering  into  a  discussion  in  which  the  weight  of  evidence 
is  decidedly  against  the  writer  just  quoted,  it  may  be  stated  that  most 
authorities  are  in  accord  in  the  belief  that  the  free  surface  of  the  organ 
(i.  e.  the  posterior  surface,  which  projects  beyond  the  hinder  fold  of 
the  broad  ligament)  is  covered  by  a  single  layer  of  short  columnar 
epithelia,  which  has  received  from  Waldeyer  the  name  ''  germinal  epi- 
thelium," because,  in  his  opinion,  the  primitive  ova  are  developed  from 
it,  the  young  ova  themselves  being  represented  by  the  occasional 
large  spheroidal  cells  with  prominent  nuclei  which  are  observed 
amonff  the  columnar  cells.^  These  are  most  numerous  in  the  ovaries 
of  young  girls,  in  which  ingroT\i:hs  of  the  germ-epithelium  into  the 
miderlying  stroma  are  sometimes  seen  (ovarial  tubes  of  Pfliiger). 
At  the  attached  border  of  the  ovary  (the  so-called  "  white  line  ")  there 
is  an  abrupt  transition  from  the  columnar  to  the  squamous  epithelium 
of  the  peritoneum. 

The  epithelial  layer  rests  directly  upon  the  tunica  albuginea,  a  thin 
layer  of  condensed  fibrous  tissue  containing  a  small  number  of  smooth 
muscular  fibres ;  although  this  capsule  is  quite  sharply  diffi?rentiated 
from  the  underlying  stroma,  the  two  are  inseparable.  The  albuginea 
does  not  become  completely  developed  until  the  third  year.  It  under- 
goes changes  corresponding  with  the  age  of  the  subject,  becoming, 
as  the  result  of  prolonged" ovulation  and  senile  atrophy,  so  dense  as 
to  resemble  fibro-cartilage.  This  physiological  change  is  undoubtedly 
often  regarded  as  pathological  by  superficial  observers.     Henle  ^  states 

'  Op.  eif.,  p.  6. 

nValdever,  EierstocJc  u.  Ei,  Leipzig,  1870;  also  Sirickei^s  Hmidhuch,  p.  545. 

^  Handhuch  der  Eingeiceidelehre. 


OVA  III  KS. 


17:; 


that  ill  man  tlirt'c  separate  layi'rs  arc  (listiii'^uisliahlc  in  the  allniirinca, 
tlic  til)n's  of  tin-  oiitci-  and  inner  li('in;j;  lontiitndinal,  wliilt-  tliii.-c  (»t'  tlic 
inidtllc  lavcr  have  a  circnlar  direction. 

Tlic  ovarian   stroma   oi"   |»arcncli\ ma   i>  <lividi'd  into   two  zones — an 
outer  ""ravisli  i-ortical  (|iai"cncli\  iiial  zone),  and  an  inner  pinki-li  niediil- 

Tn;  07. 


Longitudinal  Section  of  the  Ovary,  under  a  low  power  (Henle) :  1,  albuglnea ;  2,  fibrous  layer  of 
cortical  portion ;  3,  cellular  layer  of  cortical  portion ;  4,  medullary  substance ;  5,  loose  con- 
nective tis.sue  between  the  firm  medullary  layers. 

larv  (zona  vasculo.sa).  There  is  no  essential  diiference  between  the 
structure  of  the  two,  except  that  the  latter  is  softer  and  more  vascular. 
The  cortex  is  composed  of  bundles  of  connective  ti.ssue,  among 
which  are  scattered  ela.stic  and  mu.scular  fibres ;  imbedded  in  the  ti.s- 
sue are  numbers  of  Graafian  vesicles  of  the  smallest  size.  Under  tlic 
micro.scope  the  cortical  zone  presents  an  outer  layer  (called  l)y  Henle 
the  "fibrous"  layer),  in  which  the  fibrous  tissue  is  firmer  than  in  the 
deeper  portion,  the  bundles  of  fibres  forming;  a  dense  network.  In 
the  deejier  ]iart  of  the  cortical  zone  the  connective  tissue  is  looser  and 
has  a  radiating  appearance  from  the  centre  toward  the  periphery'.  A 
curious  feature  of  the  tissue  here  is  the  presence  in  it  (especially  in  the 
vicinity  of  the  vesicle.*)  of  numbers  of  cells,  both  round  and  fusiform. 


174        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

some  of  the  latter  possibly  representing  bundles  of  smooth  muscle- 
fibres.  There  was  formerly  much  difference  of  opinion  as  to  the  sig- 
nificance of  these  spindle-cells,  many  authorities  denying  that  they 
were  fibre-cells.  There  is  little  doubt  that  the  stroma  contains  a  con- 
siderable amount  of  muscular  tissue,  which  is  most  abundant  in  the 
neighborhood  of  the  larger  vessels.  The  majority  of  these  fusiform 
cells,  which  have  prominent  oval  nuclei,  doubtless  belong  to  connective 
tissue  in  an  early  stage  of  development.  This  inference  is  justified, 
1,  by  the  fact  that  the  cells  are,  as  a  rule,  shorter  and  broader  than 
the  fibre-cells  in  the  muscular  strata  of  the  uterine  wall ;  2,  by  the 
variable  size  of  the  cells,  some  of  which  are  short  and  nearly  oval  in 
shape,  while  others  are  long  and  tapering,  showing  that  there  is  some 
process  of  growth  or  development  going  on  among  them ;  3,  the 
cells  are  seldom  arranged  in  groups,  as  in  smooth  muscle,  but  are 
scattered  throughout  the  connective  tissue,  to  w^hich  they  bear  an 
intimate  relation.  Some  authorities  go  so  far  as  to  say  that  all  of 
the  spindle-cells  in  the  stroma  represent  muscular  tissue.  Of  the 
round  and  polyhedral  cells  scattered  throughout  the  stroma,  some  are 
leucocytes,  Avhile  others  come  from  the  foetal  Wolffian  body  and  are 
analogous  to  the  interstitial  cells  of  the  testicle ;  some  of  the  round 


Vertical  Section  through  the  Ovary  of  a  newborn  Infant  (Waldeyer) :  a,  germinal  epithelium  -■ 
6,  ovarial  tube;  c,  primitive  ova;  d,  longer  tubes  becoming  constricted  to  form  Graafian, 
vesicles ;  e,  large  cell-nests ;  /,  isolated  ovisacs ;  g,  g,  blood-vessels. 

cells,  as  well  as  the  fusiform,  undoubtedly  belong  to  the  young  con- 
nective tissue  type.  Into  the  cortical  zone  (in  the  ovaries  of  young 
subjects)  project  those  curious  cell-columns  before  alluded  to  under  the 
name  "  ovarial  tubes."  They  are  simply  ingrowths  from  the  layer  of 
germ-epithelium,  with  which  they  are  directly  continuous.     A  detailed 


ov.mih's.  17-> 

ilcscriptiiiii  111"  tlioc  Ix-luii^s  ralliiT  lo  tlic  |)i'<tviiicc  of  f'iiil)r\-((l(t;j;v.' 
From  tlic  lai'uc  inmilx'r  ol"  small  ovisacs  lliat  cxi.-l  in  the  <oi-tical 
lavcr  it  lias  Ih'cii  called  hy  Sappc  v  roiir/ic  oi'nji'ne.  Hut  not  all  of  tlicsc 
hodics  (IcstTvc  tlif  name  oliliaaHan  vesicles,  si  m-c  man\'  ol'tiii'm  irj»r»- 
st'Mt  miMviy  collections  of  embryonal  cells  that  have  not  yet  reached 
the  diiiiiitv  ol"  Ihlly-rornied  vesicles,  while  othei's  an;  p;ronj)s  of  f'attv 
dejjenei'atcd  cj)ithelial  cells.  The  Nc^icles  will  he  dcscrilKHl  se|)aratcl\-. 
The  vascular  supply  ot'the  cortex  is  not  so  rich  as  that  ol'  the  medulla. 
The  lar<:-er  and  nie(lium-sized  arteries  are  surrounded  hy  I'ascicidi  of 
elastic  and  muscular  lihi'cs.  Kach  of  the  ovisacs  is  surrounded  hv  a 
tine  nctwoi'k  of  capillariis. 

In  the  medullary  portion  of"  the  ovary  the  character  of  the  stroma 
iinderii;t)es  a  chan*>e ;  it  becomes  looser  and  more  vascular.  Although 
the  tissue  contains  the  same  elements  as  in  the  parenchyma,  the  bundles 
(»f  liijrous  and  elastic  tissue  and  smooth  muscle-fibres  are  not  so  close 
together,  but  interlace  in  all  directions.  The  non-striped  muscle  may 
be  traced  directly  through  the  liilum  (with  the  blood-vessels)  into  the 
broad  ligament.  The  bands  of  fibrous  tissue  also  radiate  from  the 
hilum,  as  well  as  the  nerves  and  vessels.  The  blood-vessels  of  the 
parenchyma  are  large  and  numerous.  Entering  the  ovary  at  the 
hilum,  the  arteries  pursue  a  spiral  course  through  the  stroma,  their 
branches  terminating  in  ca])illary  networks  around  the  vesicles.  The 
veins,  which  begin  in  small  efferent  twigs  from  the  above-mentioned 
plexuses,  are  tortuous  like  the  arteries,  and  may  be  traced  to  the  hilum, 
M'here  they  leave  the  ovary  to  enter  the  bulb.  The  lymphatic  supply 
of  the  ])arenchyma  is  particularly  rich.  By  means  of  j^'ojier  injec- 
tions the  distribution  is  seen  to  be  similar  to  that  of  the  arteries  and 
veins.  Each  vesicle  is  surrounded  by  a  fine  network  of  lymphatics, 
while  the  ultimate  termination  of  the  system  is  in  the  plexuses  of  the 
broad  ligament.  As  was  stated  before,  both  the  arteries  and  veins 
present  an  appearance  on  cross-section  similar  to  that  of  the  uterine 
vessels.  The  lumina  of  the  arteries  are  small  in  comparison  with 
their  diameters,  their  fibrous  and  muscular  coats  being  quite  thick, 
while  the  veins  are  imbedded  in  the  fibrous  stroma  with  which  they 
are  surrounded.  The  smooth  muscle-fibres  are  especially  distinct 
around  the  larger  arteries. 

The  nerve-fil)res  can  be  traced  from  the  hilum  into  the  stroma  in 
the  vicinity  of  the  larger  vessels,  but  their  ultimate  endings  in 
man  have  not  yet  been  described.  Elischer  of  Buda-Pesth  has 
studied  the  ovaries  of  the  lower  animals  with  a  view  to  settling  the 
question  of  the  termination  of  the  nerves.  He  states  as  the  result 
of  his  observations  that   medullated  fibres  after  entering  the  hilum 

'  Vidp  F.  M.  Balfour,  Treatise  on  Comp.  Embryology.  Quaiu  {Anat.,  9lh  ed.)  gives  a 
full  bibliography. 


176         THE  ANATOMY  OF  THE  FE3IALE  PELVIC  ORGANS. 

brauch  iu  a  dichotomoiis  manner,  and  lose  their  medullary  sheath 
when  they  reach  the  neighborhood  of  the  vesicles,  around  which  they 
form  looiJS.  The  larger  the  vesicle,  the  more  distinct  is  its  nervous 
plexus ;  a  fine  secondary  network  arises  from  the  primar}'-  filament  and 
rests  upon  the  outer  layer  of  the  membrana  granulosa.  The  same 
observer  claims  that  he  has  traced  the  terminal  fibrils  to  the  cells  of 
the  granular  layer,  where  they  probably  end  in  the  nuclei.  The  larger 
vessels,  he  says,  are  also  surrounded  by  plexuses  of  nerves. 

Graafian  Vesicles. — The  stroma  of  .the  ovary  constitutes  merely  the 
framework  or  bed  in  Avhich  rest  the  ovisacs.  The  former  may  be  said  to 
exist  simply  for  the  nourishment  of  the  latter.  In  order  to  under- 
stand properly  the  nature  of  these  important  bodies,  it  will  be  necessary 
to  trace  briefly  their  development  and  ultimate  fate.  For  details  the 
reader  is  referred  to  works  on  embryology. 

Whether  the  vesicles  are  formed  from  ingrowths  of  the  germ-epithe- 
liiun,  according  to  Pfliiger's  theory,  or,  per  contra,  by  outgrowths  of 
the  stroma  into  the  epithelial  layer,  as  Balfour  believes,  or,  as  Klein 
suggests,  by  "  mutual  ingro^^i:h "  of  both  epithelium  and  stroma,  cer- 
tain it  is  that  at  an  early  stage  in  foetal  life  groups  of  cells  undergo  a 
special  differentiation.  Some  of  these  cells  become  enlarged  and  their 
nuclei  prominent,  forming  the  primitive  ova,  while  others  of  the  same 
group  remain  as  the  membrana  granulosa.  In  the  ovary  of  an  infant 
there  is  seen  immediately  beneath  the  tunica  albuginea  a  granular 
layer  which,  when  examined  under  a  low  power,  appears  to  be  filled 
with  minute  bodies  that  represent  immature  vesicles  ;  still  deeper  in  the 
substance  of  the  organ  are  larger  vesicles  containing  ova.  Toward 
the  time  of  puberty  these  latter  vesicles  increase  in  size  and  advance 
from  the  deeper  part  of  the  stroma  into  the  cortical  zone.  They  con- 
tinue to  enlarge,  make  their  way  through  the  albuginea  (the  tissue  of 
the  latter  becoming  atrophied),  and  form  small  projections  on  the  sur- 
face of  the  ovary.  The  fluid  contents  of  the  vesicle  increase,  its  wall 
becomes  thinned,  especially  at  one  point,  toward  which  the  vessels  run 
(stigma),  and  ultimately  rupture  takes  place. 

The  mature  vesicles  vary  greatly  in  size,  the  largest  being  about 
2^th  of  an  inch  in  diameter,  while  the  smallest  may  not  exceed  yo¥*^^ 
of  an  inch.  Each  vesicle  has  an  external  covering  of  connective  tissue 
(tunica  fibrosa,  theca  folliculi  externa  of  Heule)  which  may  be  sep- 
arated into  tw^o  layers — an  outer,  containing  the  vascular  plexuses 
before  alluded  to,  and  an  inner,  in  which  are  the  delicate  capillaries 
that  supply  nourishment  to  the  ovum.  The  external  stratum  is  merely 
a  condensation  of  the  stroma,  and  hence  in  it  are  seen  numbers  of  the 
spindle-cells  that  fill  the  tissue  of  the  former ;  the  inner  is  more  com- 
plex in  its  stracture,  and  contains  a  variety  of  cells,  round,  polygonal, 
stellate,  and  fusiform.     The  round  cells  possess  the  amoeboid  propeiiy 


OVARIES.  177 

(tl'  li'iicoc'vtes.  The  iiiiiucdiatc  lining-  dI"  the  vesicle  is  a  laver  of  Hal 
eells  witli  siiiirle  oval  iiiielei,  external  to  wliidi  is  a  layer  ttl'  enlmmiar 
epitlielia.  The  latter  rest  ii|)()n  a  delicate  stratum  lA'  c<jmieetiv<'  tis>iio 
known  as  the  menibraiui  pr()j)ria.  The  interior  of  the  ovisac  is  mostly 
filled  l)V  a  clear  alhuiniiiuiis  lluid,  in  which  float  a  few  fatty  particles 
and  eells  (liijnor  f'oUieidi),  while  at  one  side  of  the  cavity  (<j:enerally 
that  most  removeil  from  the  surface  of  the  ovary)  there  will  he  seen 
a  delicate  transparent  body — sometimes  two,  rarely  three — snrroinide<l 
by  a  collection  of  cells  from  the  membrana  granulosa,  called  the  discus 
proligerus.  The  cells  forming  the  latter  have  been  divided  into  two 
layers — the  "eg<i-ei)ithelium,"  that  lies  adjacent  to  the  ovum,  and  the 
"  follicular  epithelium,"  which  is  external  to  the  former. 

The  ovum  itself  has  been  aptly  called  "  a  typical  cell."  It  is  a  yel- 
low, spherical  body  having  a  diameter  of  about  ^^jyth  of  an  inch,  sur- 
rounding which  is  a  thin  hyaline  membrane  (vitelline  membrane,  zona 
pellucida),  which  is  doubtless  formed  from  the  innermost  cells  of  the 
discus  proligerus.  Within  the  zona  pellucida  (in  which  fine  pores 
have  been  described)  is  the  vitellus,  a  mass  of  granular  fibrillated 
protoplasm  containing  numerous  fat-globules,  the  central  portion  of  the 
protoplasm  being  less  opaque  than  the  peripheral.  Somewhere  on  the 
outer  edge  of  the  central  zone  of  the  vitellus  is  a  light  spot,  which 
under  a  high  power  appears  as  a  delicate  network  of  fibrillated  proto- 
plasm, in  the  meshes  of  which  is  a  quantity  of  finely  granular  material, 
the  whole  being  enclosed  in  a  distinct  membrane  (nucleus  or  germinal 
vesicle).  AVithin  the  latter  is  a  small,  highly-refracting  granular 
body  (nucleolus  or  germinal  spot),  not  over  g-g^g-jjth  of  an  inch  in 
diameter,  which  occupies  the  same  relative  position  to  the  contents  of 
the  vesicle  that  the  latter  does  to  the  interior  of  the  ovum.  A\"hen 
strongly  magnified  the  nucleolus  appears  only  as  a  mass  of  finely 
granular  material.  This  brief  description  applies  to  a  mature  ovisac, 
such  is  as  seen  at  the  periphery  or  on  the  surface  of  the  ovar\\ 
Between  these  and  the  undeveloped  vesicles  (ytoT^^^  ^^  ^°  ^^^^^  "^ 
diameter)  there  are  ovisacs  of  various  sizes  and  forms.  In  the  small 
and  medium-sized  ones  the  cavity  is  entirely  filled  by  the  o\'um.  As 
the  vesicles  increase  in  size  the  latter  becomes  larger  and  occupies  a 
relatively  smaller  portion  of  their  interior,  while  the  zona  pellucida 
becomes  thicker. 

It  is  impossible  in  this  place  to  study  the  interesting  subject  of  the 
degeneration,  or  arreste<l  development,  of  the  ovisacs.  Doubtless  the 
small,  irregidar  collections  of  epithelial  cells  scattered  about  in  the 
stroma,  the  localized  thickenings  of  the  latter  (not  unlike  cicatrices  in 
their  microscopical  structure),  and  other  anomalous  appearances  fre- 
quently described  as  pathological,  all  represent  the  remains  of  Graaf- 
ian bodies  that  have  perished,  as  it  were,  in  the  midst  of  the  stroma, 

Vol.  I.— 12 


178         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

without  ever  coming  to  maturity  or  being  able  to  reach  the  surface. 
The  mere  mention  of  these  facts  will  serve  to  indicate  to  the  reader 
the  possibilities  that  lie  before  the  original  worker.^ 

In  considering  the  unruptured  vesicle  and  its  contents  we  have 
referred  only  to  the  initial  period  in  its  history.  If  such  a  vesicle  be 
examined  just  as  it  is  on  the  point  of  rupturing,  it  will  be  found  to  be 
distended  to  its  utmost  capacity,  while  over  its  thin,  transparent  wall 
run  engorged  capillaries.  Immediately  after  rupture  the  cavity  is  filled 
with  coagulated  blood  derived  from  the  torn  vessels.  A  few  weeks 
later  the  periphery  of  the  clot  has  become  of  a  yellowish  color,  while 
its  centre  has  more  of  a  reddish-gray  hue.  The  walls  of  the  cavity 
contract,  compress  the  clot,  and  thus  throw  the  yellow  zone  into  the 
convolutions  which  are  so  familiar  to  every  one.  The  mass  is  now 
known  as  the  corpus  luteum.  The  yellow  ring  increases  in  width, 
gradually  encroaching  upon  the  central  portion,  until  almost  the  entire 
mass  becomes  yellow.  As  viewed  under  the  microscope  the  change 
may  be  briefly  explained  as  follows  :  The  original  peripheral  zone  of  the 
corpus  luteum  consists  of  fatty  degenerated  cells  from  the  membrana 
granulosa,  into  the  midst  of  which  penetrate  offshoots  of  fibrous  tissue 
and  capillary  vessels  derived  from  the  wall  of  the  ovisac.  In  the  centre 
of  the  clot  there  will  be  seen  many  large  pigmented  cells  and  crystals 
of  hfematoiclin,  together  with  newly-formed  blood-vessels.  Ultimately 
the  pigment  disappears,  and  the  fatty  cells  (which  give  the  yellow  tinge 
to  the  mass)  encroach  upon  the  central  zone  until  it  loses  its  original 
appearance  entirely,  and  is  represented  by  a  small  quantity  of  mucoid 
tissue.  The  final  stage  of  retrogression  is  the  transformation  of  the 
cells  into  a  mass  of  fat-globules,  the  vessels  disappearing.  The  fat  is 
then  absorbed,  the  surrounding  fibrous  tissue  contracts,  and  a  white 
depressed  cicatrix  (corpus  albicans)  alone  remains  to  mark  the  site  of 
the  former  vesicle.  If  the  ovum  from  the  vesicle  in  question  becomes 
impregnated,  the  degenerative  changes  are  retarded,  and  the  corpus 
luteum  is  nourished  for  some  time  by  the  rich  development  and  per- 
sistence of  the  newly-formed  vessels ;  hence  it  becomes  larger  than  the 
one  just  described,  while  the  convoluted  appearance  of  its  yellow  border 
is  much  more  striking.^ 

It  will  be  evident  to  the  reader,  even  after  this  superficial  view  of 
the  minute  anatomy  of  the  ovary,  that  its  structure  is  not  only  a  com- 
plex .one,  but  that  it  is  not  always  easy  to  state  when  the  organ  is 
entirely  normal  and  when  it  is  not.  The  fact  that  it  is  the  seat  of 
constant  changes,  beginning  in  foetal  life  and  continuing  till  after  the 
menopause,  should  lead  us  to  be  cautious  in  giving  an  opinion  as  to 

^  For  an  ingenious  essay  on  the  fate  of  the  ova  see  Dr.  Creighton's  paper  in  the 

Journal  of  Anat.  and  Physiol.,  vol.  xiii. 

^  Refer  to  Dalton's  Physiology  for  details  and  illustrations. 


OVA  in  lis.  179 

tlic  pi'cx'iicc  III"  ;il)ii(iriii;il  cniidii  i(iii>.  Wlicllicr  wr  f.XMiiiiiic  crit ical l\' 
the  sti'oiiia  oi"  the  Dvisacs,  the  (•<tiirliisioii  is  unavoidnWlc  that  the  Ixjiind- 
arv-Iinc  Itciwccii  the  iioiMiial  and  |iath()l()<:;ical  is  not  a  fixed  one.  Thus 
the  de;j,'enei'ative  ehanjics  eonse(|Ucnt  upon  the  senile  state  may  easily 
he  nii>tak(ii  I'oi"  cii'i'littsis,  while  (lie  dia^jjnosis  of  cystic  defjjeneratioii 
may  In-  made  heeansc  of  the  presence  of  a  few  vesicles  that  are  some- 
what ahove  the  usual  >i/.c,  tliouiih  lliey  may  contain  perf"eet  ova. 
The  j)i-ac(ical  deduction  is  self-evident.  Tlic  (lia}z;nosis  of  ovarian 
disease  rccpiircs  for  its  support  the  aid  of  the  microscope,  as  well  as  a 
ihorouiih  acipiaintance  on  the  part  of  the  observer  with  all  of  the  pos- 
sible variations  in  the  a])pearance  of  the  normal  organ. 

The  ovai'y  receives  a  portion  of  its  blood  from  the  ovarian  artery  (Fig. 
49),  which  arises  directly  from  the  aorta,  like  the  spermatic  in  the  male, 
and  has  a  course  similar  to  that  vessel  until  it  reaches  the  pelvis. 
Having  reached  a  point  near  the  pelvic  brim,  the  ovarian  artery  makes 
a  bend  inward,  enters  the  broad  ligament,  and  runs  between  the  folds 
of  pcritoneun  upward  and  inw^ard  to  the  upper  angle  of  the  uterus. 
In  its  tortuous  course  and  in  the  manner  of  distribution  of  its  branches 
it  resembles  the  sj)leuic  artery.  On  reaching  the  uterus,  or  just  before,  it 
divides  into  two  branches,  one  of  which  supplies  the  fundus  and  joins 
the  vessel  of  the  opposite  side,  while  the  lower  and  larger  branch 
descends  along  the  lateral  border  of  the  uterus,  giving  oif  numerous 
parellel  twigs  of  a  curious  spiral  form,  and  finally  anastomoses  with 
the  uterine  artery.  Soon  after  entering  the  broad  ligament,  the  ovarian 
vessel  sends  three  or  four  large  branches  to  the  distal  end  of  the  tu1)e, 
then  a  group  of  extremely  tortuous  vessels  which  ramify  over  the  sur- 
face of  the  ovary  and  cuter  the  hilum.  Near  the  point  of  division 
other  tw^igs  are  given  off,  whicli  run  to  the  proximal  end  of  the  tube, 
Avhilc  there  is  a  special  branch  to  the  round  ligament.  It  is  impossi- 
ble to  give  a  clear  view  of  the  richness  of  the  vascular  supply  of  the 
pelvic  organs  and  of  the  intricate  anastomosis  which  takes  jilace 
between  the  vessels  that  run  in  the  broad  ligaments.  A  glance  at 
one  of  Hyrtl's  or  Savage's  plates  will  teach  more  than  pages  of 
description.  The  reader  is  referred  to  these  as  the  best  substitutes 
for  actual  dissections,  wliich  latter  arc  not  only  very  difficult,  but 
require  careful  ])reliminary  injections.  xVttention  should  be  called  to 
the  most  marked  peculiarity  of  the  ovarian  artery,  Avhich  extends  to  its 
minutest  branches — its  extreme  tortuosity.  It  is  hardly  necessary  to 
remind  the  reader  of  the  physiological  fact  that  this  peculiarity  is  one 
observed  in  many  arteries  which  sujiply  organs  of  the  turgescent  tvjie.^ 

The  ovarian  capillaries  tei'minate  in  veins  that  emerge  from  the 
hilum  and  enter  a  mass  of  veins  which  is  situated  along  the  lower 

'  Sappey  ( Traite  cV Anntomir,  Paris,  1S74,  tome  iv.  p.  691 )  denies  tlie  truth  of  Kouget's 
assertion  that  the  ovarv  is  an  erectile  bodv. 


180        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

edge  of  the  organ  and  is  known  as  the  "  bulb."  Savage  describes  it 
as  a  "  chib-shaped  venous  body  in  which  the  ovary  and  utero-ovarian 
ligament  are  partly  imbedded,"  It  communicates  freely  with  the  veins 
from  the  upper  part  of  the  uterus  and  from  the  tube  (as  well  as  with 
the  uterine  plexus),  forming  with  them  an  intricate  network,  known  as 
the  ovarian  or  pampiniform  plexus.  This  plexus  terminates  in  the 
ovarian  or  sjjermatic  vein,  which  on  the  right  side  empties  directly 
into  the  vena  cava  inferior,  but  on  the  left  joins  the  corresponding 
renal  vein.  There  is  a  well-marked  valve  at  the  termination  of  the 
right,  but  not  of  the  left,  spermatic  vein.^ 

Reference  has  been  made  to  the  distribution  of  the  nerves  and  lym- 
phatics. The  lymphatics  of  the  ovary  unite  with  those  from  the  tube 
and  upper  portion  of  the  uterus,  and  enter  the  hmibar  glands.  The 
nerves  arise  from  the   spermatic  plexus  and   accompany  the  arteries. 

Parovarium. 

Definition. — A  triangular  group  of  small  tubules  situated  in  that 
portion  of  the  broad  ligament  which  intervenes  between  the  outer  end 
of  the  ovary  and  the  distal  extremity  of  the  Fallopian  tube.  The 
apex  of  the  triangle  touches  the  upper  border  of  the  ovary. 

This  curious  body,  analogous  in  its  structure  to  the  epididymis,  is 
usually  dismissed  by  anatomists  in  a  few  words  as  the  "  remains  of  the 
Wolffian  body."  Doran^  deplores  the  general  want  of  interest  that 
prevails  with  reference  to  a  structure  that  ought  to  be  regarded  by 
gynecologists  as  of  no  little  importance,  because  of  its  relation  to 
certain  morbid  growths.  The  tubes  or  fibrils  forming  the  parovarium 
vary  considerably  in  number.  There  may  be  only  half  a  dozen,  or  as 
many  as  twenty-five  or  thirty.  They  lie  in  the  midst  of  the  delicate 
cellular  tissue  which  exists  between  the  folds  of  the  broad  ligaments, 
and  have  no  close  attachment  to  any  of  the  surrounding  parts.  Begin- 
ning at  or  near  the  hilum  of  the  ovary,  they  ascend  in  parallel  rows 
and  enter  a  transverse  tube  or  canal  which  terminates  in  a  cul-de-sac 
— sometimes  in  a  cystic  dilatation — near  the  fimbriated  extremity  of  the 
tube.  Beyond  the  point  at  which  the  lumen  of  this  transverse  tube 
disappears,  the  latter  can  still  be  traced  as  a  delicate  cord  which  extends 
inward  toward  the  uterus,  but  is  lost  before  it  reaches  that  organ.  This 
is  the  persistent  duct  of  Gartner,  which  Doran  found  in  upward  of  one- 
fifth  of  the  specimens  examined  by  him.  Attempts  have  been  made  to 
trace  a  direct  connection  between  these  ducts  and  the  so-called  ^'Skene's 
glands"  at  the  meatus  urinarius,  but  Dr.  Schiiller^  of  Berlin  has  dis- 

^  For  a  discussion  of  the  practical  significance  of  this  fact,  vide  Tait,  op.  cit.,  pp.  7-9. 
^  Tumors  of  the  Ovary  and  Broad  Ligament,  London,  1885. 
^  Beitrdge  zur  Anatomie  der  Weibl.  Harnrohre,  Berlin,  1883. 


pMiovMnrM.  181 

proved  tlic  tlicoiMcs  ol"  liis  |»i'ct|cc('ss(»rs.  'I'hc  \(i-iic,il  ihIks  arc  ol'  dil- 
I'crciit  si/i'S  and  show  \ari(iiis  decrees  of  (l('\('li>|»iiniil,  those  wliifli  arc 
most  iiitiTiial  hciiii;-  ticiicrally  iiici-cly  threads  oi'  lil»i'(tiis  tissue,  while 
a  hair  dozen  of  more  of  the  external  t nlmlo  >lio\\  nnder  the  miero- 
seope  a  well-mai'ked  himen,  which  is  lined  hy  a  single  layef  of  cili- 
ated columnar  epithelium  resting-  upon  a  line  memhrana  j)ro|)ria.  The 
latt<'i' consists  ol"  lihrons  tissue  containing'  a  small  (jiiantity  ol*  snioot  Ji 
mnscle  :  two  layers  have  been  desei'ihed,  the  onter  consistiiiji;  ol"  circii- 
lai'  lihres,  while  the  inner  rnn  in  a  loniiitndinal  direction.  This  de- 
scription aj)plies  to  an  c\eej)tionally  pei'lect  tnhiile.  As  a  I'nie,  the 
Inmen,  it'  it  exists  at  all,  is  Idled  with  a  mass  ol'  deji'enerated  ej)itiie- 
lial  cells  ind)ed(k'd  in  a  mucoid  Hnid.  The  duct  of  (Jartner  is  sel- 
dom anythinti'  more  than  a  lihrons  cord.  Cystic  dilatations  avc  fre- 
(piently  observed  in  the  course  of  the  tubides,  the  most  common  bein*^ 
the  j)e<lunculated  vesicle  known  as  the  "hydatid  of  Morj^agni,"  the 
j)e<licle  of  which  s|)l•in^'s  from  a  ])oint  in  the  mesosalpinx  to  the  innci" 
side  of  the  limbria  ovariea.  It  is  generally  regarded  as  the  result  of 
dilatation  of  the  up])er  extremity  of  the  frctal  duet  of  Miiller.  The 
other  eysts  around  and  within  the  ])arovariuni  are  really  pathological 
ai)pea  ranees. 

PiJACTiCAL  Deductions. — Can  the  normal  ovaries  be  detected  by 
the  bimanual  touch?  Opinions  on  this  subject  vary.  In  thin  snb- 
jeets  the  ])raetised  examiner  may  be  able  to  feel  them,  but  we  ven- 
ture to  affirm  that  it  is  only  under  the  most  favorable  circumstances 
that  they  can  be  felt  through  the  abdominal  Avail.  By  practising  the 
rectal  or  vesical  touch,  the  uterus  and  its  appendages  being  at  the 
same  time  depressed  from  above  or  draAvn  down  from  below,  the 
gland  may  often  be  distinctly  recognized.  According  to  Munde,  the 
normal  ovary  is  not  so  insensitive  as  has  been  claimed,  but  a  peculiar 
sickening  pain  can  be  produced  by  deep  pressure  upon  it.  The  mobil- 
ity of  the  normal  organ,  as  well  as  its  situation  in  the  pelvis,  prevents 
it  from  being  reached  through  the  vaginal  fornix  ;  hence  A\hen  it  is 
readily  felt  by  the  vaginal  touch  alone,  the  inference  is  that  it  has 
sunk  below  its  normal  ])lane. 

Rememl)ering  the  rather  loose  attachments  of  the  ovary,  and  the 
fact  that  it  "  floats  at  a  certain  level "  in  the  pelvis,  the  etiology  of 
prolapsus  becomes  almost  self-evident.  Stretching  of  the  ovarian  lig- 
ament or  increase  in  weight  of  the  organ  (both  conditions  being  a  nor- 
mal accompaniment  of  pregnancy)  will  naturally  destroy  its  adjustment 
and  cause  it  to  sink  downward.  Traction,  from  displacement  of  the 
uterus,  adhesions,  enlargement  and  ]u-ola})se  of  the  tube,  etc.,  is  a  com- 
mon cause.  As  the  ovaries  sink  downward  and  backward  (the  usual 
course),  they  rest  at  first  uj)on  the  "retro-ovarian  shelves,"  as  Polk  has 
called  the  two  sections  of  the  posterior  fossa  of  the  pelvis  that  lie  above 


182        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

the  level  of  the  sacro-uterine  ligaments  ;  subsequently  they  may  descend 
into  Douglas's  pouch.  Every  reader  must  have  noticed  the  greater 
frequency  with  which  the  left  ovary  is  thus  displaced.  This  diifer- 
ence  is  explained  by  reference  to  the  fact  that  the  left  ovary  is  more 
often  diseased — a  fact  which  depends  upon  a  chain  of  anatomical  causes, 
not  the  least  of  which  is  the  valveless  condition  of  the  left  spermatic 
vein,  so  that  this  vessel  is  readily  affected  by  any  obstruction  to  the 
general  circulation.  The  rectum  encroaches  on  the  left  retro-ovarian 
shelf,  so  that  the  corresponding  ovary  tends  to  glide  off"  from  it  into  the 
true  pouch  of  Douglas.  The  anatomical  relations  of  the  displaced  organ 
explain  the  pains  which  attend  defecation,  as  well  as  coitus ;  these  are 
especially  aggravated  when  the  organ  is  fixed  in  its  abnormal  position. 
From  the  brief  statements  which  were  made  regarding  displacement 
of  a  diseased  tube,  with  or  without  the  corresponding  ovary,  it  will  be 
inferred  that  not  only  the  shape,  but  the  position  of  a  tender  body  behind 
the  uterus,  may  give  some  clue  as  to  whether  it  is  an  ovary  or  a  tube. 
A  positive  differential  diagnosis  is  seldom  possible  at  the  examining- 
table.  Although  the  circulation  in  the  ovarian  vessels  is  doubtless 
interfered  with  when  the  gland  is  much  displaced,  there  is  probably 
less  obstruction  than  there  would  be  if  they  were  not  so  long  and 
tortuous. 

When  the  ovary  becomes  the  seat  of  tumors,  its  relations  to  neighbor- 
ing organs  are  greatly  changed ;  still,  by  remembering  them,  we  are 
often  enabled  not  only  to  make  a  correct  diagnosis,  but  to  explain  cer- 
tain complications.  Among  the  points  to  be  borne  in  mind,  the  most 
important  is  the  position  of  an  ovarian  tumor  (at  least  before  it  has 
grown  so  large  as  to  fill  the  abdomen)  with  reference  to  the  uterus — 
i.  e.  at  the  side  of  that  organ.  The  attachment  of  the  tube  and  meso- 
salpinx to  a  pelvic  tumor  always  gives  a  clue  to  its  origin,  even  when 
its  nature  is  not  clear  at  the  time  of  the  operation. 

The  relations  of  the  ovary  to  the  broad  ligament,  as  well  as  to  the 
'Fallopian  tube,  indicate  frviitful  sources  of  disease;  the  well-known 
frequency  of  localized  peritonitis  around  the  distal  extremity  of  the 
tube  requires  no  comment.  05phoritis  and  perioophoritis  are  hardly 
separable ;  how  many  of  the  symptoms  observed  in  these  cases  are  due 
to  disease  of  the  ovary,  and  how  many  to  the  surrounding  peritonitis,  it 
is  not  often  possible  to  decide. 

The  normal  anatomy  of  the  gland  should  be  thoroughly  studied  at 
the  present  day  when  so  many  ovaries  are  removed  for  real,  or  sup- 
posed, disease.  From  what  has  been  said  regarding  the  variations  in 
shape,  size,  and  external  appearance,  it  may  be  inferred  that  there  are 
many  opportunities  for  error  when  we  attempt  to  decide  delicate  shades 
of  difference  bet^veen  the  normal  and  pathological  by  a  hasty  inspection 
of  the  organ.    The  normal  histology  of  the  ovary  is  a  key  to  the  know- 


UREruiiA.  is;; 

Icd^c  of  till'  I'tiolo^v  of  its  (lisciisi's.  \\v  must  he  tlHtmiijflily  liiiniliar 
with  tlic  MpiM'iiniMcc  (iltlic  stroma  in  order  to  dclrct  liypci-tropliy  ol'llic 
liliroiis  tissue;  with  the  (iranliaii  vesicles  in  order  to  reeojrni/c  small 
patlioloii'ieal  evsts;  while  a  study  (»!"  the  e|»ithelial  eoNerill)^  is  a  licccs- 
sarv  introduction  to  that  of  cyst-formation.  The  ehanjics  in  the  cortex 
resultinu,'  from  the  ru]»ture  of  ovisacs  or  from  senility  must  he  carefully 
distiniiuished  from  the  thickeiiin<;s  due  to  chronic  inilammation. 

The  remarks  conc<'rning-  the  <;('neral  pelvic  circulation  c<iver  that  of 
the  ovary.  The  a  r  ran  foment  of  its  vessels  is  such  as  to  i:i\or  sud<len 
and  excessive  euii-ori:'ement,  whicli  niifrlit  easily  become  ])atholo;iieal. 
Suhperitoneal  ha'matoma,  the  I'csult  of  hemorrhaue  from  the  ovarian 
vessels,  is  readily  eoncei\al)le,  and  donhtless  uocurs  at  the  time  of  the 
menstrual  period  more  fretpiently  than  wo  ima<:;ine.  Hemorrhage  into 
Graafian  vesicles,  and  tlienec  into  the  peritoneal  cavity,  has  often  been 
recorded,  and  Savage  has  shown  by  a  series  of  interesting  cases  how-  the 
snbovarian  plexuses  may  ru])ture  and  fatal  hemorrhage  ensue.  The  sud- 
den appearanee  of  acute  abdominal  pain  and  collapse  during  menstrua- 
tion should  at  once  a\vaken  the  snspicion  that  this  accident  may  luue 
occnrred,  even  when  no  information  can  be  derived  from  a  physical 
examination.  The  treatment,  with  onr  modern  views  on  abdominal 
surgery,  is  evident.  The  intimate  relation  between  the  vessels  sup- 
plying the  pelvic  organs  precludes  the  possibihty  of  engorgement  in 
one  without  at  least  some  disturbance  in  the  rest.  Thus  the  ovary- 
sympathizes  with  uterine  affections.  It  is  the  centre  of  reflex  neuroses 
which  are  not  always  explicable  by  reference  to  anatomical  facts ; 
mammary  pain  (generally  on  the  same  side  as  a  diseased  ovary)  is 
a  familiar  example. 

To  the  various  neoplasms  and  their  origin  we  can  only  refer ;  that 
they  are  formed  from  pre-existing  elements  will  be  evident  to  the 
student  of  normal  histology. 


THE  URINARY  TRACT. 
That  portion  of  the  tract  which  is  usually  described  with  the  genital 
organs  includes  the  urethra,  the  bladder,  and  the  termination  of  the 
ureters.     These  will   be   considered    in   the   same  order   as  were  the 
genital  organs — that  is,  from  below  upward. 

Urethra. 

Syxonyms. —  Gr.,  obprjdpa  ;  Laf.,  canalis  urinarius,  urethra,  iter  uri- 
narium ;  Ft:,  urethre,  uretre ;   Ger.,  Harnrohre ;  Sp.  and  //.,  uretra. 

Definition. — The  female  urethra  is  a  short  canal  imbedded  in  the 
anterior  vaginal  wall,  extending  from  the  meatus  urinarius  to  the  neck 
of  the  bladder. 


184        THE  ANATOMY   OF  THE  FEMALE  PELVIC  ORGANS. 


In  a  mesial  section  of  the  pelvis  the  urethra  appears  as  a  slit  nearly- 
straight,  or,  as  some  authors  describe  it,  with  a  slight  sigmoid  curve 
corresponding  to  that  of  the  posterior  vaginal  wall.^      Its  course  is 

Fig.  59. 


Frozen  Section  of  the  Pelvis,  sliowing  contracted  bladder  and  relations  of  urethra :  a,  anuS; 
b,  vagina  ;  c,  bladder  ;  d,  uterus  ;  e,  bottom  of  Douglas  s  pouch  ;  /,  symphysis  pubis  (Fiirst). 

upward  and  backward,  being  "  parallel  with  the  plane  of  the  pelvic 
brim."  Henle  states  that  in  cross-sections  the  canal  is  represented  by 
a  transverse  slit  near  its  vesical  end,  while  at  other  points,  except  at 
the  meatus,  the  section  has  a  stellate  appearance.  The  average  length 
of  the  urethra  is  one  and  three-eighths  inches,  the  average  diameter  a 
quarter  of  an  inch.  For  the  sake  of  convenience  we  may  consider 
first  the  beginning  of  the  canal,  then  the  portion  that  lies  between  its 
two  openings,  and  lastly  the  vesical  extremity. 

"When  in  a  state  of  rest   the   meatus    appears  as  a  small    dimple, 

or  puckering,  of  the  mucous  membrane,  situated  in  the  median  line 

at  the  lower  edge  of  the  vestibule,  from  three-fourths  to  four-fifths 

of  an   inch   below  the    clitoris   and   an    inch    in   front   of  the   four- 

'  Winckel,  Krankheiten  der  Weibl.  Harnrohre  u.  Bkm,  S.  5. 


vniyniiiA.  185 

chette,  A  cross-sect  ion  of  tlw  canal  at  this  iioiiit  is  rcprosentccl  l»y  a 
vertical  slit.  The  corrn<;ati()n  of  (he  nnicoiis  nicinhrane  is  not  coiilincd 
to  the  nieatns,  hut  exists  thi'on<;;hont  the  whole  c(Mirse  of  the  urethi'a 
when  it  is  not  ilistendi'd.  The  pnckerinji'  nl'thc  nuicosa  at  the  external 
opening:;  is  dne  to  the  sphincter  action  of  the  nniscnlar  Hbres  w'hich 
siu'roiMid  it.  Around  the  nii-atus  there  will  be  observed  on  close  inspec- 
tion several  little  (le[)ressi()ns,  which  are  the  openin<i;s  of  the  glandnlie 
vestibnlares  niinores,  already  alluded  to  in  connection  with  the  vestibuh;. 
Just  within  the  meatus  are  the  orifices  of  a  })air  of  <>;lands  described  by 
Dr.  Skene.'  These  are  simply  two  of  I^ittre's  glands  of  large  size, 
corresponding  to  the  lacuna  major  in  the  fossa  navicularis  of  the 
penis.  They  are  not  always  easy  to  find  in  the  healthy  urethra,  but 
in  cases  of  prolapse  of  the  mucous  membrane  they  often  stand  out 
prominently.  J^r.  Skene  describes  them  as  tubules,  situated  just 
beneath  the  mucous  membrane  near  the  floor  of  the  urethra,  and 
extending  nj)ward  from  the  meatus  parallel  with  the  canal  for  a  dis- 
tance of  three-quarters  of  an  inch  ;  their  function  is  unknown.  They 
derive  a  certain  patlK)l()gical  interest  from  the  fact  that  they  are  some- 
times the  seat  of  an  inflammatory  process,  Avhich  may  hjng  resist  treat- 
ment until  its  true  site  is  discovered. 

The  mucous  membrane  of  the  meatus,  as  well  as  that  of  the  lower 
portion  of  the  urinary  tract,  is  covered  Avith  pavement  epithelium  sim- 
ilar to  that  of  the  vestibule.  The  glands  (like  those  near  the  end  <jf 
the  penis)  arc  lined  at  their  nujiiths  with  squamous  epithelium,  Avhich 
soon  passes  into  the  columnar  variety.  The  venous  plexuses  around 
the  meatus  are  apparent  even  on  superficial  inspection.  The  distri- 
bution of  the  vessels  and  nerves  is  the  same  as  in  other  parts  of  the  ves- 
tibular area. 

The  urethra  lies  beneath  the  pubic  arch,  suspended  by  the  pubo- 
vesical ligament,  and  pierces  the  triangular  ligament,  to  the  tw'O  layers 
of  wdiich  it  bears  the  same  relations  as  the  canal  in  the  male.  In  its 
anterior  three-fourths  it  is  literally  imbedded  in  the  anterior  vaginal 
wall,  while  the  upper  fourth  is  intimately  connected  with  the  vagina  bv 
an  intermediate  layer  of  cellular  tissue.  The  fusion  of  the  walls  of  the 
two  canals  results  in  the  formation  of  the  urethro-vaginal  septum,  Avhich 
is  nearly  half  an  inch  in  thickness. 

Anatomy. — a.  Gross. — Three  layers  of  tissue  are  present  in  the 
urethral  wall,  two  of  which  are  muscular  and  the  third  nnicous.  An 
external  layer  of  cellular  tissue  is  sometimes  described,  but  it  is  well 
marked  only  over  the  upper  portion  of  the  canal.  The  outer  muscular 
layer  consists  of  smooth  fibres  disposed  in  a  circular  manner  around  the 
tube,  while  those  of  the  internal  layer  run  longitudinallv.     Uffleman 

'  For  details  and  drawings  consult  vSkene's  original  article  in  the  Am.  Jouni.  of 
Obstetrics,  vol.  xiii. 


186        THE  AXATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

describes  a  double  layer  of  voluntary  muscle  (the  inner  fibres  being 
transverse,  the  outer  longitudinal)  which  extends  from  the  neck  of  the 
bladder  to  a  point  halfway  to  the  meatus,  below  which  point  it  invests 
only  the  anterior  half  of  the  canal.  Tliis  muscle  is  regarded  by  the 
writer  quoted  as  a  voluntary  sphincter.  His  observations  have  not 
been  generally  confirmed,  although  WinckeP  appears  to  regard  them 
as  reliable.  Luschka^  describes  a  sphincter  muscle  common  to  both  the 
lower  end  of  the  urethra  and  the  vaginal  orifice.  It  is  a  tliin  muscular 
band,  about  six  millimeters  in  breadth,  surrounding  both  the  introitus 
vaginae  and  the  urethra,  and  continuous  behind  mth  the  deep  trans- 
versus  perinei.  It  serves  to  compress  the  urinary  canal  against  the  firm 
urethro- vaginal  septum.  Another  urethral  sphincter,  known  as  "  Guth- 
rie's muscle,"  is  described  by  Savage  as  existing  just  in  front  of  the 
sphincter  vesicae,  of  which  it  is  probably  the  prolongation.^  By  fol- 
lowing the  circular  layers  of  smooth  muscle  throughout  their  entire 
course,  it  "svill  be  found  that  it  is  incomplete  over  the  lower  half  of  the 
tube,  where  the  fibres  blend  with  those  of  the  vaginal  wall.  The  long- 
itudinal fibres  are  continuous  above  with  the  inner  longitudinal  layer 
of  the  bladder.  The  mucous  membrane,  when  in  a  state  of  rest,  is  of 
a  pinkish  color,  and  is  thrown  into  longitudinal  folds  by  reason  of  the 
large  amount  of  elastic  tissue  that  is  contained  within  it. 

B.  Minute. — In  a  cross-section  of  the  urethra  the  following  points  are 
to  be  noted :  Exterior  to  the  canal  is  a  plexus  of  large  veins,  which  are 
especially  abundant  at  the  sides.  These  are  situated  in  the  midst  of  a 
mass  of  loose  cellular  tissue,  which  is  seen  in  its  true  relation  to  the 
urethra  within  the  urethro-vaginal  septum,  Avhere  it  appears  under  the 
microscope  as  forming  a  line  of  separation  between  the  two  portions 
of  the  septum.  Over  the  anterior  wall  of  the  canal  its  connection  is 
less  intimate.  The  fibres  have  both  a  circular  and  a  longitudinal 
course.  Internal  to  the  cellular  layer  are  the  longitudinal  muscular 
fibres,  which  are  recognized  by  the  fact  that  their  spindle-cells  are 
divided  longitudinally.  Between  the  two  muscular  layers,  and  serv- 
ing to  unite  them,  is  a  venous  plexus  enclosed  in  loose  connective  tis- 
sue. In  the  transverse  muscular  layer  the  fibres  run  in  several  direc- 
tions, not  all  of  them  being  disposed  in  a  circular  manner,  so  that  the 
fibre-cells  will  be  divided  in  different  planes.  Internal  to  the  muscular 
coat  is  a  thick  submucous  layer  consisting  of  fibrous  and  elastic  tissue,  and 
containing  a  plexus  of  large  veins,  some  of  which  are  really  sinuses ;  so 
that  this  tissue  may  be  regarded  as  analogous  in  its  character  to  the  cor- 
pus cavernosum  of  the  penis.  From  the  submucosa  elastic  fibres  extend 
into  the  mucous  membrane,  and  numerous  papillae  are  formed,  as  in  other 
mucous  tracts,  by  projections  of  fibrous  tissue  from  the  subjacent  layer,, 

■*  Op.  cit.,  p.  6.  ^  Anat  des  MenscM:  Beckens. 

"*  See  Guthrie,  Anatomy  and  Diseases  of  the  Geiiito^irinary  Orgasm. 


URETIin. 


187 


Fk;.  (10. 


which  tiro  covered  hy  epithelium  ami  contain  h)r»j)s  ol'  capilhiries.  The 
mucous  linino-  of  the  urethra  is  rich  in  ehistie  lihrcs,  and  is  (piitc  vascu- 
hu*.  Tlie  epithelium  ex)verin>:;  its  upper  portion  is  ut"  the  sit-ealled  transi- 
tional tyj)e,  liUe  that  of  the  hhuMer; 
that  is,  it  consists  of  a  superficial 
layer  t)f  coluiunar  cells  restin<<  upon 
a  layer  of  cuhical  epithelium,  and 
this  on  one  of  round  cells.  Near 
the  orifice  the  cells  become  squam- 
ous, closely  resemhliui;'  those  of  the 
vagina,  except  that  they  are  some- 
what smaller.  At  the  meatus  they 
pass  into  the  larger  squamous  va- 
riety. In  addition  to  the  papillae 
numerous  glands  are  scattered 
throughout  the  mucous  membrane, 
as  well  as  lacunae,  the  latter  being- 
surrounded  near  the  meatus  by 
villous  tufts.  The  glands  are  lined 
by  columnar  epithelium,  while  the 
lacunte  have  a  partial  lining  of 
squamous  cells  near  their  mouths ; 
the  latter  become  columnar  at  a 
short  distance  from  the  free  sur- 
face. Attention  should  be  called 
to  the  presence  of  collections  of 
lymph-corpuscles  ^\'ithin  the  mu- 
cous membrane,  which  give  to  it 
in  some  places  almost  the  appear- 
ance of  adenoid  tissue.^ 

A  separate  description  of  the 
minute  anatomy  of  the  septum  is 
hardly  necessary.  The  intimate 
relation  between  the  walls  of  the 
two  canals  can  be  better  appreciated  by  a  study  of  the  accompanying 
figure  than  by  a  detailed  statement  of  the  anatomy  of  the  parts,  to 
which  reference  has  already  been  made. 

The  vesical  opening  of  the  urethra  is  situated  about  four-fifths  of  an 
inch  below,  or  behind,  the  middle  of  the  symphysis  pubis  and  an  inch 
and  a  quarter  from  the  cervix  uteri,  and  will  be  described  in  connection 
with  the  bladder.  Hcnle  states  that  a  cross-section  of  the  canal  at  this 
point  presents  the  appearance  of  a  transverse  slit,  Simon  and  "SVinekel 
claim  that  it  is  diagonal,  Holden  tliat  the  opening  is  infundibular, 

'  Satterthwaite,  op.  ciL,  p.  242. 


Horizontal  Section  of  the  Vesico-vaginal 
Septum  (Henle) :  a,  vesical  epithelium;  6, 
submucosa;  c,  layer  of  circular  fibres;  d, 
layer  of  longitudinal  fibres  ;  e,  loose  cellu- 
lar tissue ;  /,  layer  of  circular  fibres ;  g^ 
longitudinal  layer;  /(.submucosa;  /.vagi- 
nal epithelium. 


188         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

while  Savage  figures  the  same  as  triangular.  The  determination  of 
this  point  in.  the  living  subject  is  obviously  extremely  difficult,  if  not 
impossible,  and  is  of  no  consequence  from  a  practical  standpoint.  The 
longitudinal  folds  in  the  mucous  membrane  are  especially  marked  at 
this  extremity  of  the  canal.^ 


Bladder. 

Syxonyms. —  6rr.,  xuarcQ',  Lot.,  vesica  urinaria;  Fr.,  vessie;  Ger., 
Harnblase ;  It,  vescica ;  Sp.,  vejiga. 

Definition. — A  hollow  muscular  organ,  situated  in  the  anterior 
part  of  the  pelvis,  between  the  symphysis  pubis  in  front  and  the 
vagina  and  uterus  behind. 

In  the  living  subject  the  shape  of  the  bladder  is  constantly  changing 
as  it  is  filled  and  emptied,  so  that  it  is  not  easy  to  state  what  its  normal 
dimensions  are.  Its  shape  and  size  vary  at  different  ages.  In  infancy 
it  aj)proaches  the  masculine  type,  the  vertical  diameter  being  the  longer, 
in  the  mature  female  the  transverse  diameter  is  the  greater,  while  in  the 
senile  state  there  is  a  return  to  the  infantile  condition.  When  empty  the 
viscus  appears  as  a  collapsed  sac,  which  lies  behind  the  pubes  and  is  par- 
tially concealed  by  the  fundus  uteri.  As  it  becomes  distended  with  urine 
it  gradually  rises  from  behind  the  symphysis,  appearing  as  an  ovoidal 
body,  that  pushes  upward  the  fundus  of  the  uterus  and  fills  the  anterior 
pelvic  segment.  The  usual  shape  of  the  empty  bladder,  as  viewed  in 
mesial  sections  of  frozen  bodies,  is  that  of  the  letter  Y,  the  vertical  leg 
of  which  is  formed  by  the  urethra,  while  the  oblique  legs  may  be  of 
equal  length,  or  the  posterior  one  the  longer  (Hart).  Hart  and  Bar- 
bour have  also  figured  a  mesial  section  of  the  empty  bladder  in  which 
that  viscus  is  represented  as  of  an  oval  shape,  the  latter  probably  repre- 
senting the  bladder  in  a  condition  of  systole.  In  the  living  subject  the 
contracted  organ  is  more  nearly  round  :  this  is  ascribed  by  Savage  to  its 
inherent  tonicity.  Except  during  the  act  of  urination  the  bladder  is 
flaccid  and  possesses  no  definite  shape.  When  moderately  distended  it 
becomes  round ;  when  fully  distended,  transversely  oval.  According 
to  Henle  and  Luschka,  the  bladder  of  the  female  is  smaller  than  that 
of  the  male,  though  others  affirm  that  it  is  capable  of  greater  disten- 
sion. Unlike  the  male  organ,  its  transverse  diameter  is  larger  than  the 
vertical  (Fig.  61). 

Anatomy. — a.  Gross. — The  bladder  is  divided  into  three  regions — 
the  body,  base  or  fundus,  and  neck.  The  former  is  defined  by  Skene 
as  "  all  that  portion  of  the  organ  lying  above  an  imaginary  line  drawn 
from  the  ureteric  openings  to  the  centre  of  the  symphysis  pubis." 

1  For  other  details  vide  Blum,  "  Des  Affections  de  I'Urethre  chez  la  Femme,"  Arch, 
gen.  de  Med.,  1877,  vol.  ii. 


llLAUDKll.  l.SO 

'riic  jturlidii  below  this  phiiic  is  the  I'iiikIiis  or  Ikisc,  wliidi  iiiclii<lcs 
the  triu'ono,  or  tlic  triaiiii'iilar  s|»:uv  Ix'twccii  the  iii'ctliral  and  iii'ctcric 
opeuinjis,  and  tlu'  has  loud,  or  pai't  o("  the  iiiiidiis  hcliind  tlic  oj)cii- 
ings  of  tlu'  uri'ttTs.  Tlii'  latter  may  even  hi-  a  dee|)  |M»neli,  especially 
in  old  snbjeet.s.  The  thickened  portion  aronnd  the  nrethral  orilico  is 
the  iieeU;  it  is  the  must  dependent  part  oi"  the  organ  when  the  body 
is  ereet. 

The  bonndaries  of  the  different  reuions  are  clearly  reeogni/.ed  only 
by  exaniinini;'  the  interior  of  the  bladder.  The  most  prominent  land- 
mark is  the  vesical  orifice,  which  forms  the  apex  of  the  trigone,  where 
the  nuicons  membrane  is  thrown  into  longitudinal  folds.  The  uvula, 
a  distinct  elevation  at  the  a})ex  of  the  triangle  in  the  male  bladder,  is 
only  faintly  marked  in  the  female.  The  base  of  this  area  is  formed  by 
an  imaginary  line  joining  the  o])enings  of  the  ureters,  M'hieh  appear  as 
small  slits  distant  from  eaeh  other  and  from  the  urethral  orifiee  about 
an  inch  and  a  half,  so  that  the  triangle  is  equilateral.  It  is  smaller 
than  the  corresponding  region  in  the  male  bladder,  and  is  not  so  clearly 
defined. 

The  bladder  is  essentially  a  muscular  organ.  Its  wall,  Mhich  varies 
in  thickness  from  one-sixth  to  one-half  an  inch,  according  to  the  de- 
gree of  distension  (Savage),  consists  of  two  layers  of  muscle  with  the 
usual  mucous  lining.  The  exterior  of  the  viscus  is  partially  covered 
by  peritoneum,  as  will  be  explained  subsequently.  This  muscular  coat 
consists  of  an  outer  longitudinal  and  an  inner  circular  stratum,  but  a 
distinct  separation  of  the  two  is  not  possible,  as  the  fibres  interlace  in 
an  intricate  manner.  The  longitudinal  fibres  (of  the  unstripcd  variety), 
which  are  beautifully  shown  when  the  fully-distended  bladder  is  held 
before  a  light,  are  mostly  confined  to  the  anterior  and  posterior  aspects. 
They  may  be  traced  from  the  vesical  neck  and  pubes  in  front  (where 
they  are  called  the  musculi  pubo-vesicales)  over  the  anterior  surface  of 
the  organ  to  the  summit,  whence  a  few  fibres  extend  over  the  urachus, 
and  then  downward  over  the  posterior  to  the  under  surface  of  the  neck, 
where  they  blend  with  the  anterior  vaginal  wall.  At  the  sides  this  layer 
is  represented  by  a  few  pale  interlacing  fibres  (Fig.  61). 

The  circular  fibres  are  best  developed  around  the  vesical  orifice,  where 
they  form  the  sphincter  vesicae. ^  Their  transverse  direction  is  only 
maintained  in  the  region  of  the  fundus,  especially  at  the  trigone,  while 
above  this  point  they  cross  one  another  in  an  oblique  manner.  Ellis^ 
describes  and  "  figures  a  submucous  stratum,"  consisting  of  a  thin  layer 
of  smooth  muscle,  the  fibres  of  which  run  in  a  longitudinal  direction 
over  the  lower  third  of  the  bladder,  and  extend  for  some  distance  along 
the  urethra.     In  the  upper  two-thirds  this  layer  is  represented  by  a  few 

^  Henle  (op.  eii).  denies  this  function  to  these  fibres. 
^Demonstrations  of  Anatomy,  p.  574. 


190 


THE  A]s\iTOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


oblique  fibres^     Between  the  muscular  and  mucous  coats  there  is  a  layer 

of  fibrous  and  elastic  tissue. 

The  mucous  membrane  of  the  emptv^  bladder  is  thrown  into  numerous 

folds  by  reason  of  its  loose  attachment  to  the  underlying  tissue,  except 

at  the  trigone,  where  it  is  thinner 
than  at  other  points,  and  is  more 
intimately  connected  with  the  sub- 
mucous layer.  Its  color  has  been 
variously  described.  As  viewed 
through  the  endoscope  in  the  liv- 
ing subject,  it  has  always  appeared 
to  the  writer  to  present  a  pinkish 
or  rosy  hue.  Shortly  after  death  it 
assumes  a  slatv'  color,  with  here  and 
there  pinkish  areas  due  to  localized 
hyperemia.    The  mucosa  is  directly 


continuous  wath  that  lining  the  ure- 
thra and  ureters ;  around  the  open- 
ings of  these  canals  it  is  more  firmly 
adherent  than  elsewhere. 

B.  Minute. — The  mucous  mem- 
brane is  the  chief  object  of  interest 
microscopically,  the  muscular  layers  presenting  the  same  appearances 
as  in  other  hollow  organs,  except  that  their  division  into  separate  strata 
is  less  distinct  than  usual.     Klein  ^  instances  the  bladder  as  an  organ  in 


Muscular  Fibres  of  the  Bladder,  lateral  view 
(Allen  Thompson)  :  a,  a',  a",  decussating 
longitudinal  fibres;  6,  b',  diverging  fibres; 
b",  divergent  fibres  surrounding  entrance 
of  ureter ;  c,  deep  layer  of  circular  fibres. 


Fig.  62. 


Epithelium  of  the  Bladder  (Obersteiner) :  a,  cell  from  the  second  layer :  b,  cell  from  the  super- 
ficial layer  ;  c,  the  three  layers  as  seen  in  vertical  section. 

which  the  bundles  of  fibres  form  plexuses.     This  membrane  is  sup- 
ported by  the  submucous  stratum,  which  is  composed  of  bundles  of 
'■  For  further  details  vide  Boyd  Med.-Chir.  Transactions  for  1856.         ^  Op.  cif.,  p.  64. 


i;lai>1)i:i:.  Hil 

fild'uiis  ami  clastic  ti->uc,  in  tlic  nicslics  of  wliidi  arc  networks  of  ves- 
sels ami  a  limited  ninnlxT  ot"  l\  in|)liatics  and  nerve-|)lexu,s(?H,  iiiclii<liii^ 
lianvilia.  .Ner\'e-lil)res  are  also  visible  tliroMuliont  the  niiisciilar  coat  and 
jnst  lu'iieatli  the  |)eritoiienm.  The  epithelial  lining- «jt"  the  bladder  con- 
sists of  thi'ee  or  nioic  layers  ot"  cells  resting  upon  a  nienibrana  propria, 
and  presentin^•  a  typical  exani))le  of  the  "transitional  "  typ(.'  (Fig.  02). 
Tiie  superficial  cells  ai'e  S([uaiuous  (but  smaller  than  those  of  the 
vagina) ;  the  inferior  layer  consists  of  eolunuiar  epithelia  with  long 
pr(»eesses,  and  the  middle  of  pyriform  cells.  Over  the  trigone  the 
mucosa  is  thinner  and  luore  intimately  related  to  the  submucous 
stratum.  The  nuicous  membrane  contains  a  rich  plexus  of  fine  capil- 
laries and  nerve-iibres,  the  latter  being  most  numerous  in  the  region 
of  the  trigone ;  they  have  been  traced  as  far  as  the  cells,  but  the  exact 
manner  of  their  termination  is  obscure.  The  lymphatic  supply  of  the 
tissue  is  poor.  Sections  of  the  vesical  wall  in  the  region  of  the  ure- 
thral opening  show  that  the  mucosa  is  thicker  here  than  at  other  points, 
so  that  it  may  form,  as  Hart  and  Barbour  suggest,  the  real  barrier  to 
the  escape  of  urine.  The  uvula  is  formed  by  a  localized  thickening  of 
the  submucosa.  Savage  maintained  that  there  are  neither  villi  nor 
glands  in  the  lining  membrane  of  the  bladder.  The  former  are  cer- 
tainly absent,  but  later  investigations  have  demonstrated  beyond  a 
doubt  the  existence  of  small  lacunre  and  racemose  mucous  glands  lined 
with  cylindrical  epithelium,  the  latter  being  most  numerous  near  the 
neck  of  the  bladder. 

The  organ  derives  its  vascular  supply  from  the  anterior  division  of 
the  internal  iliac  artery,  through  the  medium  of  the  three  vesical  branches 
and  a  branch  from  the  uterine.     These  vessels  anastomose  freely. 

The  arterial  supply  of  the  urethra  is  received  from  the  branches  that 
are  distributed  to  the  anterior  vaginal  ^vall.  The  vaginal  artery  sends 
a  twig  to  the  region  around  the  vesical  neck.  The  venous  plexuses  are 
large  and  intricate ;  they  cover  the  exterior  of  the  organ  lying  outside 
of  the  muscular  coat,  and  are  largest  around  the  base  and  neck.  The 
latter  plexuses  communicate  with  those  of  the  uterus,  vagina,  nymphse, 
and  rectum,  and  empty  into  the  internal  iliac  vein.  The  urethra  has 
its  own  venous  plexus,  which  is  intimately  related  to  the  vaginal  veins. 

The  lymphatics  from  the  submucous  stratum  and  exterior  of  the 
bladder  accompany  the  veins,  and  finally  enter  the  glands  near  the 
internal  iliac  artery.  The  nerves  belong  to  both  the  sympathetic  and 
cerebro-spinal  systems,  the  former  being  derived  from  the  hypogastric 
plexus,  and  supplying  the  bladder  in  common  with  the  other  pelvic 
organs.  The  latter  nerves  are  branches  of  the  third  and  fourth  sacral, 
and  are  distributed  mainly  around  the  base  and  neck. 

Relations  axd  Attach:mexts. — Anteriorly  the  bladder  is  sepa- 
rated from  the  posterior  surface  of  the  symphysis  pubis  by  the  retro- 


192        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

pubic  fat,  which  latter  tissue  assumes  a  triangular  shape  when  the  viscus 
is  empty.  The  anterior  surface  of  the  organ  is  entirely  devoid  of  peri- 
toneum ;  as  it  rises  above  the  pubes  it  approaches  closely  to  the  anterior 
abdominal  wall.  The  summit  of  the  bladder  and  a  portion  of  the  pos- 
terior wall  are  covered  by  peritoneum.  The  former  is  only  in  contact 
with  coils  of  small  intestine  when  the  organ  rises  out  of  the  pelvis ; 
under  normal  conditions  the  vesico-uterine  pouch  does  not  contain 
intestine.  As  the  bladder  becomes  empty  the  uterus  inclines  forward, 
resting  upon — or,  more  correctly,  over — the  summit,  w^hile  the  coils  of 
small  intestine  ghde  backward.  Below  the  level  of  the  os  internum 
the  peritoneal  investment  of  the  posterior  wall  is  wanting,  and  the 
latter  is  united  to  the  upper  part  of  the  anterior  vaginal  wall  by  means 
of  an  intervening  layer  of  dense  fibrous  tissue. 

The  neck  of  the  bladder  and  the  upper  fourth  of  the  urethra  have 
the  same  attachment  to  the  vaginal  wall,  the  entire  thickness  of  the 
tissue  separating  the  cavities  of  the  bladder  and  vagina  being  knoAvn  as 
the  vesico-vaginal  septum.  Above  the  upper  limit  of  the  septum  is  a 
subperitoneal  space,  intervening  betAveen  the  posterior  vesical  wall  and 
the  cervix  uteri ;  this  is  filled  with  a  small  quantity  of  loose  cellular 
tissue.  The  round  ligaments  cross  the  lateral  walls  of  the  bladder, 
while  above  and  behind  the  summit  are  the  broad  ligaments  with 
their  contents. 

The  relations  of  the  ureters  will  be  described  later.  The  so-called 
true  and  false  ligaments  will  be  mentioned  under  the  sections  treating 
of  the  pelvic  connective  tissue  and  peritoneum,  of  which  they  .form 
parts.  The  attachments  of  the  urachus  and  obliterated  hypogastric 
arteries  are  the  same  as  in  the  male  bladder. 

Ureters. — Their  course  previous  to  entering  the  pelvis  is  the  same  as 
in  the  male.  Their  relations  within  the  pelvis  have  been  studied  with 
great  care  in  connection  with  the  obstetrical  operation  known  as  gastro- 
elytrotomy.^  In  the  non-pregnant  woman  they  are  nearly  parallel  in 
the  upper  part  of  their  course  until  they  cross  the  iliac  arteries  (the  left 
ureter  lying  behind  the  sigmoid  flexure,  the  right  behind  the  lower  end 
of  the  ileum),  when  they  extend  downward,  backward,  and  outward 
along  the  lateral  walls  of  the  pelvis  until  near  the  spine  of  the 
ischium,  where  they  bend  downward,  forward,  and  inward  behind 
the  uterine  vessels.  Passing  beneath  the  bases  of  the  broad  liga- 
ments, they  converge  behind  the  cendx  uteri,  and  enter  the  bladder 
from  one-half  to  three-quarters  of  an  inch  in  front  of,  and  below,  it. 
The  distance  between  the  two  ureters  just  as  they  reach  the  bladder 
is  about  two  inches.     They  run  in  the  muscular  coat  of  that  organ 

^  Garrigues  and  Polk  have  investigated  this  subject  quite  thoroughly.  Comp.  Gar- 
rigues's  papers  in  Am.  Journ.  ObsteL,  Jan.,  1883 ;  N.  Y.  Med.  Journ.,  Oct.  and  Nov., 
1878 ;  and  Polk's  in  the  N.  Y.  Med.  Journ.,  May,  1882,  and  Am.  Journ.  ObsteL,  Jan.,  1883. 


nL.innhi:. 


1  \m 


Vui.  (j:i. 


r 


|i»r  ;i  (li-taiiff  of  a  little  iin'iv  than  half  an  inch,  still  cmvorpnjj:,  so 
that  their  internal  (•luninjis  are  .-«e|)arate<l  from  each  <ither  hy  only  an 
inch  or  an  inch  and  a  hail",  and  irom  the  anterior  lip  of  the  eervix 
bv  a  space  of  tliree-(|narters  of  ;ui  inch.  .Inst  before  enterin);  the 
bladder  they  lie  in  the  mass  of 
cellular  tissue  which  is  iinme- 
tliately  above  the  lateral  walls 
of  the  vauina.  As  each  ureter 
pierees  the  muscidar  coat  of 
the  bladder  its  circular  fibres 
blend  with  those  of  the  iiuier 
or  eireular  layer,  while  the 
lono;itudinal  are  prolonged  in- 
ward to  meet  those  of  the  op- 
posite side,  forming  the  "  inter- 
ureteric  ligament "  of  Juerie, 
which  is  represented  by  a 
transverse  ridge  extending  be- 
tween the  ureteric  openings  and 
constituting  the  base  of  the 
vesical  triangle.     The  slit-like 

orifices  of  the  ureters  are  pro-  Relations  of  the  ureters  at  the  level  of  the  OS  inter- 
tceted     bv     valvidar     f(^>lds     of  num  as    seen  from  above  (Polk):  U,  uterus:  B. 

,  rp  bladder;  if.  rectum ;  ^,.4,  uterine  arteries;  C  C, 

mucous        membrane.  iWO         ureters ;  L,  L,  mero-sacralligaments. 

faintly-marked      bundles     of 

smooth  muscular  fibres  (rudimentary  in  the  female)  have  been 
described  as  arising  from  the  so-called  vesical  sphincter,  and  passing 
beneath  the  base,  to  be  attached  near  the  terminations  of  the  ureters. 
The  function  of  these  muscles,  as  well  as  of  the  interureteric  band, 
seems  to  be  to  close  the  orifices  of  those  tubes  by  drawing  upon  them, 
thus  preventing  regurgitation  during  the  act  of  urination. 

The  relations  of  the  ureters  in  the  pregnant  Avoman  are  slightly 
different  from  those  in  the  non-pregnant,  the  differences  being  thus 
summarized  by  Polk,'  who  has  made  a  special  study  of  the  sub- 
ject:  "As  a  whole,  the  tubes  in  the  pelvis  are  situated  upon  a 
higher  plane  than  in  the  non-pregnant  condition,  having  been  carried 
slightly  upward,  Avhile  being  separated  from  their  close  relations  with 
the  pelvic  wall  by  the  ascending  uterus."^  The  gross  and  microscopical 
anatomy  of  these  canals  does  not  require  a  separate  description. 

Practical  Deductions. — The  condition  of  the  bladder  is  too 
of\en  disregarded  during  an  examination  of  the  female  pelvic  organs, 

'  X  r.  Med.  Jnvrn.,  May.  1S82. 

^  See  also  Liisclika,  "Topograjjliie  d.  Ilarnleiter  d.  Weibes,"  Arch,  fur  Gi/n.,ih.  1S72, 
p.  37.3. 

Vol..  I.— 13 


194        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

although  the  symptoms  referable  to  this  organ  are  among  the  most 
common  and  distressing  of  which  women  complain.  There  is  such 
a  radical  difference  between  the  urethro-vesical  tract  in  the  sexes,  as 
regards  both  its  anatomy  and  pathology,  that  the  reader  should  not 
seek  to  draw  comparisons.  To  infer  that  a  woman  has  acute  cystitis 
because  she  has  symptoms  ordinarily  accompanying  that  disease  in  the 
male  would  imply  a  complete  ignorance  of  the  anatomy  and  physics 
of  the  pelvis. 

Let  the  reader  bear  in  mind  the  cardinal  fact  that  "the  uterus  and 
bladder  behave  practically  as  one  organ,"  so  far  as  concerns  changes  in 
position ;  in  other  words,  that  the  base  of  the  bladder  is  so  firmly 
united  to  the  uterus  that  any  displacement  of  the  latter  will  cause  trac- 
tion upon  the  former  at  its  point  of  attachment  to  the  pubes — i.  e.  the 
neck.  Thus  is  explained  the  vesical  irritation  (frequent  and  painful 
micturition)  so  common  in  acquired  anteflexion,  where  the  traction 
exerted  along  the  line  of  the  utero-sacral  ligaments  is  transmitted 
from  their  uterine  attachment  to  the  neck  of  the  bladder.  In  this 
way  a  remote  retro-uterine  inflammation  may  directly  eifect  the  blad- 
der, causing  a  permanent  disturbance  of  its  functions,  while  the  organ 
itself  remains  free  from  disease.  This  is  more  in  accord  with  anatomi- 
cal facts  than  the  theory  that  frequent  micturition  in  cases  of  ante-dis- 
placement is  due  to  the  pressure  of  the  fiuidus  uteri  on  the  bladder. 
The  effects  of  backward  displacement  upon  the  bladder  are  best 
observed  in  retroflexion  of  the  gravid  uterus,  when  the  neck  of  the 
former  organ  may  be  so  compressed  between  the  cervix  and  the  pubes 
that  retention  and  all  its  serious  consequences  may  result. 

Aside  from  the  physiological  elevation  of  the  bladder  during  preg- 
nancy, the  organ  is  .sometimes  drawn  upward  by  a  fibroid  uterus,  or 
ovarian  cyst,  in  such  a  manner  that  it  might  easily  be  wounded  by  the 
laparotomist.  The  introduction  of  a  sound  as  a  guide  is  the  only  safe- 
guard. This  precaution  is  indispensable  during  the  separation  of  the 
bladder  from  the  uterus  in  vaginal  extirpation,  a  delicate  procedure 
requiring  both  time  and  patience.  Perforation  of  the  vesical  wall  can 
only  be  avoided  by  keeping  close  to  the  uterus.  The  proximity  of  the 
bladder  to  the  organs  occupying  the  anterior  pelvic  fossa  has  suggested 
the  practice  of  the  vesical  touch,  in  which  the  finger  is  introduced 
through  the  dilated  urethra. 

That  portion  of  the  posterior  wall  of  the  viscus  which  enters  into 
the  formation  of  the  vesico-vaginal  septum  is  most  interesting  surgi- 
cally, since  it  is  the  usual  site  of  fistula  and  is  the  region  in  which  arti- 
ficial openings  are  made  into  the  bladder  for  the  removal  of  calculi, 
foreign  bodies,  or  morbid  growths,  the  relief  of  chronic  cystitis,  etc. 
This  portion  of  the  bladder  is,  of  course,  not  covered  by  peritoneum. 
Cystocele  also  occurs  in  this  locality  from  obvious  causes.     Retention 


liLAimhJi. 


]u: 


of  iirino  in  tlie  pouch  thus  formed  may  lead  to  cyf^titis  or  to  the  forma- 
tion of  t-iUi'iili.  It  will  occur  to  the  reader  that,  l»y  a<lvi>in^  a  j>atieut 
to  urinate  <tn  the  hands  and  knees,  jrravity  will  assist  in  em[)tyinj;  thi.- 
|M)neh.  There  can  \)v  no  I'xeu.se  for  dragginj^  a  larj^e  ealeulus  through  a 
dilated  urethra,  at  the  risk  of  causini;  permanent  inc<mtinencv,  when 
it  can  he  removed  so  easily  and  safely  throuj^h  an  incision  in  the  h'|>- 
tiim.  Surgical  wounds  of  the  septum  heal  so  rapidly  that  it  is  difficult 
to  maintain  a  permanent  opening  atlcr  cystotomy,  unless  the  opening 
is  madi'  with  the  thermo-cautery  or  by   Emmet's  meth<Ml. 

From  what  has;  been  said  regarding  the  course  of  the  ureters  just 
before  entering  the  bladder,  it  will  be  inferred  that  transverse  incisions 
through  the  septum  should  be  avoided,  median  longitudinal  ones  being 
safer.  As  the  mucous  membrane  of  the  vagina  is  loose  and  movable, 
we  can  only  avoid  making  an  irregular  or  valvular  opening  by  cutting 
down  directly  upon  the  end  of  a  sound,  which  presses  forward  the  sep- 
tum at  the  exact  point  at  which  it  is  proposed  to  establish  the  fistula. 
The  ureters  may  be  included  in  a  large  fistula,  and  one  or  both  of  their 
openings  can  be  seen  in  the  everted  vesical  mucosa ;  it  must  then  be 
exceedinglv  difficult  to  avoid  including  them  in  the  sutures  at  the  time 
of  operation.  Uretero-vaginal  fistulte  are  rarely  formed  in  the  fornix ; 
communications  between  a  ureter  and  the  uterine  cavity  are  still  more 
uncommon. 

The  operation  of  catheteri-  ^^' 

zation  ot  the  ureters  possesses  ^^         ^  '  ^ 

no  practical  interest  for  the 
general  reader.  In  complete 
extirpation  of  the  uterus  the 
operator  avoids  these  ducts 
by  keeping  close  to  the  cervix  ; 
in  gastro-elytrotomy  it  is  gen- 
erally acknowledged  that  the 
vagina  should  be  opened  above 
the  line  at  which  it  is  crossed 
by  the  ureter.  From  the 
limited  space  which  exists  for 
the  incision  in  the  latter  ope- 
ration, it  is  evident  that  the 
tear  may  readily  involve  the 
bladder ;  which  is,  in  fact,  a 
common     accident.        Fortu-  ^""^^^  ^^^T.f  '^^  ^''^'''"^  (Oamgues):   u 

uterus:  B,  bladder:  ur,  ureter:  «,  urethra:  V, 
nately,  wounds  of  this  visCUS  vagina,  with  x,  showing  line  of  incision  in  gastro- 
/  '•    11        ^   -^      f       ^      \   ]       1  elyirotomy:  r,  Fallopian  tube ;  O,  ovary ;  6,  broad 

^^especiauy  ar   its    lunmisj    neal  ligament;  r,  round  ligament;  ct,  connective  tis- 

quickly.  sue. 

Since  endoscopy  has  become  popular  we  have  been  able  t(»   studv 


196        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

thoroughly  the  normal  mucous  membrane  of  the  bladder,  and  conse- 
quently to  distinguish  more  definitely  the  changes  in  its  color  due  to 
disease.  It  may  be  stated  in  general,  with  regard  to  inflammation  of 
the  female  bladder,  that  it  is  capable  of  being  diagnosticated  more 
directly  (by  palpation  through  the  vagina,  etc.),  and  that  local  treat- 
ment by  means  of  irrigation,  permanent  catheterization,  and  surgical 
interference  is  more  practicable,  than  in  the  male.  Intractable  as  are 
many  cases  of  chronic  cystitis,  it  would  seem  as  if  suppuration  and 
renal  complications  should  be  of  rare  occurrence  when  the  gyne- 
cologist can  at  any  time  establish  perfect  drainage  through  an  artificial 
fistula,  and  thus  also  apply  his  remedies  directly  to  the  diseased  mucosa. 
Our  study  of  the  pelvic  nerves  has  shown  us  that  the  innervation  of 
the  genital  and  urinary  tracts  is  practically  the  same.  We  have  seen 
that  certain  affections  of  the  other  pelvic  organs  may  cause  irritation 
of  the  bladder,  and  conversely.  The  sphincter  vesicae  being  especially 
sensitive  to  these  reflex  influences,  we  need  not  wonder  that  inconti- 
nence and  retention  may  result  from  distant  causes. 

The  frequent  extension  of  malignant  disease  of  the  cervix  to  the 
bladder,  and  the  ultimate  ursemic  complications  which  may  result,  are 
well  known. 

The  female  urethra  differs  from  that  of  the  male  in  its  shortness,  its 
dilatability,  and  its  comparative  immobility.  The  first  two  peculiarities 
tempt  the  gynecologist  to  enlarge  the  canal  for  the  convenient  practice 
of  manipulations  within  the  bladder,  while  the  last  suggests  a  danger 
from  over-dilatation,  which  is  not  imaginary.  Although  there  is  a 
wide  difference  of  opinion  as  to  the  liability  to  persistent  incontinence 
after  dilatation  of  this  canal,  for  the  purpose  either  of  introducing  the 
fingers  or  of  extracting  a  foreign  body,  a  careful  study  of  its  anatomy 
must  convince  the  reader  that  this  procedure  is  not  so  harmless  as  it 
has  been  represented.  Emmet,  in  the  light  of  his  great  clinical 
experience,  strongly  condemns  it.  In  some  instances  clumsy  efforts 
to  extract  calculi  have  resulted  in  laceration  of  the  urethra.  Dr. 
Emmet  believes  that  this  laceration  is  usually  transverse,  and  is  situated 
in  front  of  the  subpubic  ligament ;  to  repair  the  injury  requires  excep- 
tional skill  in  plastic  surgery.  Urethrocele  is  believed  by  the  same 
writer  to  be  also  due  to  mechanical  injury  to  the  canal,  whereby  its 
natural  supports  are  weakened.  The  prolonged  compression  of  the 
urethral  tissues  between  the  pubes  and  the  impacted  foetal  head  is  no 
slight  cause  of  lesions.  The  most  important  surgical  operation  in  this 
region  is  the  formation  of  a  "  buttonhole,"  after  Emmet's  method. 

At  the  meatus  Skene's  glands  possess  a  practical  interest,  from  the 
inflammation  to  which  they  are  subject;  this  inflammation,  though 
localized,  is  very  obstinate,  and  can  be  cured  only  by  treatment  directed - 
to  the  glands  themselves. 


RECTUM.  107 

We  iic<'<l  not  dwell  il|inii  tlic  little  o|)cr;iti(m  of  ]»:i.-.-iii;r  tin-  <"i(  lictcr, 
Easv  as  it  aitpcars  tVuin  tlic  (k'Scni)ti(»M,  wlieii  the  l)la<l(l('r  is  drawn 
U[)\vard,  or  comin-csscd  l)y  iiiorl)id  growths,  or  the  urethra  is  encroaelied 
upon  l)v  a  larjic  fetal  head,  it  often  tests  botli  the  skill  and  tlie  anatomical 
Uno\vle<l<;c  of  the  physician.  Xothintr  ^vill  he  grained  hy  force;  the 
len-ith  aiitl  direction  of  the  canal  must  he  renieinlx'retl,  and  the  catheter 
must  he  guided  accordingly.  It  woidd  hardly  seem  necessary  to  add 
the  caution  that  the  female  bladder  is  pectdiarly  liable  to  receive  infec- 
tion froiu  unclean  instnmicnts,  and  that  the  resulting  cystitis  is  often 
extremely   intractable. 

Rectum. 

Synonyms. — ia/.,  rectum  ;  F/-.,  rectum  ;  Ger.,  Ma.stdarm  ;  It.,  retto; 
Sp.,  recto. 

Dkfixitiox. — The  rectum  is  the  lower  extremity  of  the  large  intes- 
tine and  the  termination  of  the  intestinal  tract. 

The  rectum  of  the  female,  although  it  is  not  so  intimately  connected 
with  the  genital  organs  as  the  urinary  tract,  and  is  not  the  seat  of  as 
many  atiections  which  directly  concern  the  gynecologist,  nevertheless 
deserves  careful  mention  because  of  the  relation  which  it  bears  to  the 
pelvic  c(jntents.  It  is  nr)t  enough  for  the  specialist  and  general  prac- 
titioner to  become  thoroughly  acquainted  with  these  relations  from 
an  anatomical  standpoint ;  he  must  also  be  familiar  \y\ih.  the  "  feel " 
of  those  organs  which  can  be  touched  through  the  anterior  rectal 
wall. 

The  rectum  begins  near  the  left  sacro-ihac  synchrondrosis,  extends 
downward  and  Ijackward,  and  at  the  same  time  toward  the  median  line 
of  the  body,  until  it  reaches  a  point  opposite  to  the  third  sacral  vertebra, 
^vhen  it  curves  downward  and  forAA'ard  behind  the  cervix  uteri  to  meet 
the  vagina,  the  course  of  which  canal  it  follows,  finally  making  a  sharp 
bend  Ijackward  to  its  termination.  It  thus  appears  that  the  rectum  pre- 
sents three  separate  curves,  the  first  being  from  left  to  right,  the  second 
forward,  and  the  third  directly  backward.^ 

The  reader  must  be  cautioned  against  regarding  the  rectum  as  an 
open  canal,  as  it  is  figuretl  in  many  textbooks.  A  careful  study  of 
frozen  sections,  as  well  as  observations  made  on  the  living  subject, 
jirove  that,  unless  distended  by  the  presence  of  some  foreign  body,  it  is, 
like  the  canals  of  the  genito-urinar}-  system,  simply  a  slit,  and,  more- 
over, that  during  life  the  amis  is  never  patent  under  normal  conditions, 
except  when  by  the  relaxation  of  the  sphincter  it  opens  to  allow  the 
passage  of  feces. 

^  Tlie  direction  of  the  anal  canal  is  thus  given  by  Hart  and  Barbour  {op.  cil.),  who 
base  their  statement  upon  studies  of  frozen  sections.  The  writer  is  inclined  to  believe, 
with  Kannev,  that  this  direction  is  more  nearlv  vertical. 


198        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


Fig.  65. 


Anatomy. — a.   Gross. — The  rectum  in  the  female  is  about  eight 
inches  in  length,  and  is  somewhat  less  curved  than  in  the  male,  its 

calibre  being  usually  greater.  Externally  it 
is  smooth,  non-sacculated,  and  is  destitute  of 
the  longitudinal  muscular  bands  which  are 
the  prominent  characteristics  of  the  colon. 
Although  the  lower  four  inches  of  the  canal 
are  usually  empty,  the  portion  just  above  the 
anus  is  capable  of  great  distension,  and  has 
in  consequence  been  called  the  "ampulla." 
Wlien  hyper-distended  by  artificial  means 
the  rectum  appears  to  taper  gradually  from 
the  ampulla  to  the  upper  end,  which  is  the 
narrowest  part  next  to  the  anus  ^  (Fig.  65). 
The  anal  orifice  is  very  dilatable ;  the  anus 
itself  is  not  a  mere  apertm-e,  but  a  canal,  ex- 
tending through  the  entire  thickness  of  the 
integument  and  muscles  forming  the  pelvic 
floor.  The  skin  around  the  external  opening 
is  thrown  into  a  number  of  radiating  folds, 
caused  by  the  contraction  of  the  sphincter, 
is  deeply  pigmented,  and  is  covered  with  hair 

Rectum  Inflated  (Chadwick) :  a,b,         j  cphaopmics  crlnnrlt; 
sphincter  tertius;  c,  ampulla.       ^^'^  SCDaceOUS  gianQS. 

On  exposing  the  interior  of  the  rectum 
by  an  incision  carried  through  the  entire  length  of  the  anterior  wall,  a 
number  of  folds  will  be  observed  in  the  mucous  lining.  Those  near 
the  anus  have  mostly  a  longitudinal  direction,  and  are  known  as  the 
"columns  of  Morgagni,"  the  depressions  between  them  being  called 
the  "sinuses  of  Morgagni;"  they  are  said  to  be  corrugations  of  the 
mucous  membrane  due  to  the  contraction  of  the  sjDhincter,  and  they 
nearly  all  disappear  when  the  gut  is  distended.  Higher  up  •  in  the 
bowel  are  various  circular  and  oblique  folds.  Three  of  the  latter 
variety  are  permanent ;  they  include  a  portion  of  the  muscular  as  well 
as  the  mucous  stratum,  and  are  about  half  an  inch  in  dejDth.  One  of 
these  projects  from  the  anterior  wall  at  a  distance  of  an  inch  and  a  half 
from  the  anus,^  another  is  on  the  right  side  of  the  canal,  on  a  level  with 
the  sacral  promontory,  while  a  third  is  situated  midway  between  the 
two  on  the  left  side. 

The  lowest  fold  has  been  called  "  the  valve  of  Houston,"  while  Hyrtl 
has  described  it  under  the  name  of  sphincter  ani  tertius.     The  so-called 


^  Vide  Chadwick,  ''The  Function  of  the  Anal  Sphincters,"  Trans.  Am.  Gyn.  Soc, 
vol.  ii.  p.  43. 

'^  Ellis  {op.  dt.,  p.  583)  says  that  it  is  "  three  inches  from  the  anus,  on  the  front  of 
the  rectum,  opposite  the  base  of  the  bladder." 


RECTUM.  \\yj 

^' third  sj)hiii('t('r  of  the  n-ctiiin  "  is  a  stnirtiirc  wliidi  \\:\s  n'c«'ivc<l  no 
small  aiiiuiiut  ol"  attcntidii — iiir»rc,  in  lact,llian  it  <|nitc  drsrrvfs.  Tln're 
has  hccn  much  cont  rovcrsv  n'}j;ar(linji:  its  location,  a|»|»c:iranr(',  an<l  func- 
tion. All  authorities  ai^rcc  that  folds  and  constrictions  do  exist  within 
the  rirtum,  but  they  dill'cr  widely  as  to  the  numixr  ol"  fohls  and  the 
exact  situation  of  those  which  iiirm  the  thii-d  sphincter,  CliadwieU  ' 
describes  and  fiirures  it  as  eonsistinjx  ot"  two  en'scentic  rupo,  one  of 
which  is  in  the  anterior  wall  (oorresjKindinji;  with  the  lowest  valve  of 
Houston),  while  the  other  is  an  inch  higher  uj)  in  the  posterior  wall. 
The  writer  has  seen  the  tipj>er  fold  so  ])rominent  that  it  was  mistaken 
for  a  stricture.  On  the  other  hand,  he  has  met  with  folds  in  the 
mucous  membrane  at  a  distance  of  three  or  four  inches  from  the  anus 
so  larii;e  that  they  arrested  a  rectal  tube,  but  when  the  patient  was 
exaiuinal  under  ether,  the  canal  being  exposed  with  a  Sims  speculum, 
thev  had  entirely  disappeared.^  An  extended  discussion  of  this  matter 
Woidd  he  out  of  place  here.  It  is  enough  to  state  that  the  sphincter  in 
question  is  not,  as  its  name  suggests,  a  band  encircling  the  gut,  but  a 
succession  of  valve-like  folds  situated  at  diiferent  levels  and  acting 
together  to  cause  a  certain  amount  of  constriction  of  the  canal. 

The  coats  of  the  rectum  are  three  in  number.  Like  the  bladder,  it 
has  only  a  partial  peritoneal  invastment,  the  disposition  of  which  will 
be  mentioned  subsequently.  The  muscular  coat  includes  tAvo  layers  of 
unstriped  muscle — a  superficial,  which  coasists  of  longitudinal  fibres 
similar  to  those  in  the  colon,  but  distributed  uniformly  around  the  gut 
instead  of  being  collected  in  separate  bands,  and  a  deep  layer  of  cir- 
cular fibres.  The  latter  are  best  marked -immediately  above  the  anus, 
where  they  form  a  di.stinct  ring  nearly  half  an  inch  in  width  (internal 
sphincter).  The  submucous  layer  is  common  to  the  intestine.  The 
mucous  lining  is  thicker  and  more  movable  than  that  of  the  colon,  and, 
by  reason  of  its  vascularity,  generally  appears  of  a  bright  pink,  or  even 
red,  color. 

Certain  muscles  are  attached  to  the  lower  end  of  the  rectum.  Of 
these  the  levatores  ani  are  especially  important,  as  forming  an  essential 
part  of  the  pelvic  floor ;  they  will  be  described  in  connection  Avith  that 
structure.  The  external  sphincter  is  a  thin,  pale,  elliptical  voluntar}' 
muscle  which  surrounds  the  anal  canal,  having  posteriorly  a  fibrous 
attachment  to  the  coccyx,  while  anteriorly  it  is  inserted  into  the  peri- 
neal centre,  where  it  appears  to  blend  with  the  sphincter  vaginae.  Dr. 
Emmet  has  recently  stated  that  the  opposite  fibres  of  the  sphincter  do 
not  interlace  in  front  of  the  anus,  but  run  parallel  to  each  other  up  to 
their  point  of  insertion,  being  simply  kept  in  apposition  by  transverse 

'  Op.  cit. 

*  For  an  able  article  on  this  subject  by  Kelsey  the  reader  is  referred  to  the  X  Y. 
Merf.  Journal  for  March,  1881. 


200        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


bands  of  fibrous  tissue.^  Although  this  opinion  seems  to  be  supported 
by  many  of  the  figures  in  anatomical  works,  the  writer  has  not  been 
able  to  satisfy  himself  by  his  own  dissections  of  its  absolute  correctness. 
The  relations  of  the  sphincter  to  the  perineal  body  belong  properly  to 
the  section  which  treats  of  that  subject.     Ellis  also  describes  a  delicate 

Fig.  66. 


Vertical  Section  through  Lower  Enrl  of  Rectuui  (Ruedinger) :  1,  rectal  mucous  membrane ;  2, 
line  of  separation  between  mucous  membrane  and  skin  of  buttock;  S,  fat;  4,  levator  ani; 
5,  6,  external  sphincter;  7,  internal  sphincter;  8,  9,  longitudinal  muscular  fibres  interlacing 
with  those  of  sphincter ;  10,  terminations  of  longitudinal  fibres  ;  11,  circular  fibres ;  12, 13, 
longitudinal  fibres  of  muscularis  mucosae. 

subcutaneous  layer  of  involuntary  muscle  that  "surrounds  the  anus 
with  radiating  fibres"  (corrugator  cutis  ani). 

B.  Minute. — The  muscular  coat  offers  nothing  of  particular  interest 
microscopically,  except  near  the  anus,  where  the  longitudinal  fibres 

^  A  laceration  of  the  perineum  through  the  sphincter  involves,  according  to  some 
writers,  simply  a  separation  of  the  opposite  halves  of  the  muscle,  and  not  an  actual 
laceration  of  its  fibres. 


RECTUM.  liOl 

iiUcrlacc  with  those  i^i'  the  >|ihiii(tcis  mikI  end  just  Ix'iifuth  the  iiit<'j:;- 
imient  of  the  anal    region. 

Tlie  ininuti'  anatomy  of  the  inucotis  nicnild-anc  is  similar  to  that  of 
the  eoUm,  It  is  lined  by  eolnmnar  epithelinm  and  contains  nnmhers 
of  Lieheikiihn's  I'ollieU's.  Hermann  and  Desfossos  liuve  described 
cduvoliited  glands  which  open  on  llie  live  surface  near  the  amis.' 
There  is  a  liansition  at  the  amis  from  cohimnar  to  stratifie<l  pavement 
epitheliniu.  The  so-eaili'd  "white  liiu'"  marks  the  lower  limit  of  the 
luneons   mendn'ane. 

The  vascidar  supply  of  the  rectnm  is  very  abnndant.  The  Ijranches 
of  the  three  hemorrhoidal  arteries  (of  which  the  sin)erior  arises  from 
the  inferior  mesenteric,  the  middle  iicncrally  from  the  internal  iliac, 
and  the  interior  from  the  pudie)  penetrate  tlie  muscular  coat  in  the 
upper  half  of  the  canal,  and  form  a  network  in  the  submucous  layer ; 
over  the  lower  half  they  run  downward  parallel  to  one  another,  and  to 
the  long  axis  of  the  bowel,  as  far  as  the  anus,  where  they  are  united  in- 
transverse  branches.^  The  veins  form  a  dense  plexus  (hemorrhoidal 
plexus)  in  the  submucosa,  which  communicates  with  another  plexus 
exterior  to  the  gut,  and  empties  into  those  veins  that  accompany  the 
corresponding  arteries.  These  enter  both  the  portal  and  general  venous 
systems,  the  superior  hemorrhoidal  being  a  branch  of  the  inferior 
mesenteric  vein,  while  the  middle  and  inferior  hemorrhoidal  veins 
empty  into  the  internal  iliac.  The  lymphatics  form  two  intercommu- 
nicating plexuses,  one  in  the  submucosa,  and  the  other  beneath  the 
peritoneum  and  in  the  superficial  muscular  stratum.  In  the  anal  region 
they  communicate  with  those  of  the  integument.  They  all  pass  through 
the  "lands  of  the  mesorectum  to  terminate  in  the  sacral  o;lands.  The 
sympathetic  nerves  are  derived  mostly  from  the  hypogastric  plexuses, 
those  of  the  cerebro-spinal  system  from  the  sacral  plexus. 

Relations  axd  Attachments. — The  upper  portion  of  the  rectum, 
which  is  covered  by  peritoneum,  is  in  direct  relation  anteriorly  with  the 
pouch  of  Douglas ;  the  utero-sacral  folds,  that  form  the  lateral  bound- 
aries of  the  ]iouch,  pass  on  each  side  of  the  rectum  to  reach  the  sacrum. 
When  the  bladder  is  empty  and  the  uterus  inclines  forward,  the  ante- 
rior rectal  wall  ^vill  be  in  contact  with  tlie  loops  of  small  intestine 
which  fill  the  fi^ssa.  As  the  uterus  rises  toward  the  vertical  the  small 
intestine  is  displaced  upward,  and  the  rectum  and  uterus  are  only  sepa- 
rated by  a  narrow  space,  in  which  is  a  double  fold  of  peritoneum.  If 
the  rectum  is  much  distended,  or  the  uterus  lias  a  considerable  range 
of  mobility,  the  two  may  be  in  contact,  especially  when  the  woman  is 
in  the  recumbent  posture.  On  tlie  left  side  of  this  portion  of  the  rectum 
lie  the  ureter  and  some  branches  of  the  internal  iliac  artery.  Behind  it 
is  a  fold  of  peritoneum  (mesorectum)  which  attaches  it  to  the  sacrum, 

*  Compl.  rend.,  xc,  1880.  'Quain's  Anatomy  (9th  ed.),  vol.  ii.  p.  010. 


202        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

against  which  bone  it  lies ;  it  rests  also  upon  the  left  pyriformis  muscle 
and  sacral  plexus. 

The  sacral  portion  of  the  rectum,  or  that  part  which  lies  within  the 
hollow  of  the  sacrum,  gradually  loses  its  peritoneal  covering,  first  behind, 
then  at  the  sides,  and  finally  in  front.  It  is  in  relation  anteriorly  at 
first  with  the  bottom  of  Douglas's  pouch,  which  intervenes  between 
it  and  the  upper  end  of  the  posterior  vaginal  wall ;  but  at  a  point 
about  three  inches  from  the  ostium  the  peritoneum  is  reflected  from  the 
rectum,  and  the  latter  becomes  loosely  attached  to  the  vagina  as  low  as 
an  inch  and  a  half  from  the  anus.  Here  the  rectum  bends  backward 
and  the  vagina  somewhat  forward,  so  that  a  triangular  interval  is  left 
between  the  lower  extremities  of  the  two  canals,  which  is  occupied  by 
the  perineal  body.  The  septum  separating  the  rectum  and  vagina 
where  they  lie  in  contact  (recto-vaginal  septum)  is  formed  by  their 
walls  and  a  quantity  of  loose  areolar  tissue  enclosing  some  venous 
plexuses  that  serves  to  connect  them.  The  rectum  is  attached  to  the 
sacrum  and  coccyx  by  bands  of  fibrous  tissue  containing  a  quantity  of 
fat.  Laterally,  it  receives  the  insertions  of  the  levatores  ani.  The  anal 
canal  is  in  immediate  relation  anteriorly  with  the  base  of  the  perineal 
body,  and  is  surrounded  above  by  the  external  sphincter,  and  at  its  ter- 
mination by  integument,  beneath  which  is  a  layer  of  adipose  tissue. 

Practical  Deductions. — The  principal  point  of  practical  interest 
in  the  rectum  of  the  female  is  its  relation  to  the  genital  organs.  By  the 
rectal  touch  we  are  enabled  to  distinguish,  more  clearly  than  by  the 
vaginal,  retro-uterine  tumors,  inflammatory  conditions  of  the  utero- 
sacral  ligaments,  etc.  Prolapsed  tubes  and  ovaries  and  indurations 
in  the  broad  ligaments  can  also  be  touched  through  the  rectal  wall. 
It  is  often  possible  to  replace  a  retroverted  uterus  (and  especially 
the  retro-displaced  pregnant  organ)  by  pressure  exerted  through 
the  rectum. 

That  gynecologists  emphasize  the  fact  that  habitual  constipation  is  a 
fruitful  source  and  aggravation  of  uterine  disease,  especially  of  dis- 
placements, cannot  surprise  the  reader  who  considers  the  relations  of 
the  rectum  to  the  genital  tract,  and  the  changes  in  size  and  position  of 
the  latter  which  result  from  constant  over-distension  of  the  gut.  The 
pain  occasioned  by  the  pressure  of  hardened  feces  against  a  sensitive 
ovary  or  an  acute  inflammatory  focus  can  readily  be  conceived.  Rec- 
tocele  as  a  result  of  fecal  accumulation  is  easily  understood.  The  rec- 
tum is  closely  connected  with  the  vagina,  so  that  the  two  canals  share 
some  affections  in  common ;  in  fact,  disease  of  the  former  is  sometimes 
referred  by  the  patient  to  the  latter.  Thus  rectocele  is  not,  as  its  name 
would  seem  to  imply,  a  prolapse  of  the  rectum  alone,  but  of  the  ante- 
rior rectal  and  posterior  vaginal  walls,  which  have  been  deprived  of 
their  natural  support  by  a  tear  of  the  perineal  body  (and  injury  to  the 


RECTUM.  203 

jM'Ivii'  lldiirV).     A  rnimUc  i-ccto-vaiiiiial  li.-tiila  may  <'aii.-c  an  anioimt  of 
(liscoinlort  to  the  patient  entirely  ont  ol"  j>ropoi-tion  to  its  size. 

On  aeeoiint  of  its  proximity  to  tlic  vajrina,  the  lower  end  of  tlie  re<> 
tiim  can  readily  be  examined  by  intr<Klueing  one  or  two  fingers  into  the 
former  eanal  and  everting  the  rectal  mneons  membrane  thn»ngh  the 
sphincter.  The  lower  third  of  the  recto-vaginal  septnm  generally 
shares  in  laceration  of  the  perineum  extending  through  the  sphincter; 
the  hemorrhage  at  the  time  of  the  accident,  wlien  the  circulation  has 
been  obstructed  by  prolonged  pressure  of  the  child's  head,  is  sometimes 
quite  alarming.  The  reader  need  only  recall  the  train  of  consequences 
which  ultimately  follows  this  lesion  in  order  to  rwxjgnize  the  propriety 
of  the  primary  operation  for  its  repair,  although  it  is  not  always  suc- 
cessful. The  secondar}-  operation  for  laceration  through  the  sphincter 
recjuires  as  much  skill  and  judgment  as  any  in  gynecology ;  the  diffi- 
culty of  maintaining  perfect  apposition  of  the  parts  and  rest  during 
healing  is  obvious.  From  the  anatomical  structure  of  the  torn  sphinc- 
ter and  its  constant  tendency  to  contract,  it  ofiten  fails  to  unite  per- 
fectly. The  method  of  closing  the  tear  in  the  recto-vaginal  septum 
by  suturing  the  rectal  and  vaginal  mucosa  separately,  and  then  repair- 
ing the  perineal  rupture,  including  the  sphincter,  seems  to  provide 
against  most  of  the  chances  of  failure. 

Constipation  not  only  favors  the  development  and  persistence  of 
uterine  disease,  but  it  renders  common  certain  affections  that  result 
from  obstruction  to  the,  venous  circulation,  esjiecially  hemorrhoids.  It 
LS  in  vain  to  treat  these  latter  until  the  cause  has  been  sought  for  and 
removed.  Referring  again  to  the  oft-mentioned  continuity  of  the 
pelvic  venous  plexuses,  the  writer  need  only  call  attention  to  the  fact 
that  the  obstruction  of  the  circulation  through  the  rectal  vessels  may 
be  situatcMl  in  some  remote  portion  of  the  pelvis.  If  ablation  is 
necessary,  the  operation  is  easier  than  in  the  male,  since  the  piles  are 
rendered  easily  accessible  by  everting  them  by  pressure  through  the 
vagina. 

The  reflex  symptoms  resulting  from  rectal  disease  in  the  female  are 
best  obser\'ed  in  cases  of  anal  fissure.  Besides  the  characteristic  pain 
experienced  after  defecation,  the  patient  may  suffer  from  vaginismus  or 
vesical  disturbance,  or  may  describe  symptoms  A\hich  point  to  some 
affections  of  the  internal  genital  organs.  Thorough  dilatation  of  the 
sphincter  will  remove  a  train  of  evils  which  appeared  as  formidable  as 
they  were  inexplicable.  From  the  close  proximity  of  the  anus  to  the 
\'ulva,  it  follows  that  certain  affections  of  the  latter  may  readily  extend 
to  the  former.  Thus,  pruritus  ani,  although  it  may  exist  independently, 
oflen  accompanies  pruritus  vulvse,  while  acrid  and  irritating  vaginal 
discharges,  specific  or  non-specific,  flowing  downward  over  the  anus 
while  the  patient  lies  upon  the  back,  may  cause  troubles  which  are 


204        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

rarely   found    in   that   region    in  the  male  (chancroids,  plaques,  mu- 
quenses,  etc.). 

Pelvic  abscesses  sometimes  rupture  into  the  lower  bowel,  and  con- 
tinue to  discharge  their  contents  for  months,  or  even  years,  especially 
during  defecation.  It  is  manifest  that  it  is  not  only  next  to  impossible 
to  discover  the  opening  of  such  an  abscess,  but  to  promote  healing  of 
the  sac,  since  it  is  subject  to  constant  disturbance  from  the  passage  of 
the  feces.  This  fact  is  sufficient  to  prevent  the  surgeon  from  tapping 
an  abscess,  ovarian  cyst,  or  hsematocele  through  the  rectal  wall,  or  from 
removing  a  diseased  ovary  through  this  channel,  the  latter  being  an 
operation  that  has  never  enjoyed  much  favor. 

In  addition  to  the  organs  contained  within  the  female  pelvis,  there 
are  certain  tissues  that  invest  and  supj^ort  those  organs,  with  the  anatomy 
and  relations  of  which  it  is  important  for  the  gynecologist  to  be  thoroughly 
acquainted.  These  are  arranged  to  some  extent  in  layers,  and  include, 
as  viewed  from  above  downward,  the  peritoneum^  the  connective  tissue^ 
and  the  pelvic  floor.  Each  of  these  will  be  studied  first  as  a  whole, 
and  then  in  its  relations  to  individual  organs.  It  is  assumed  that  the 
reader  is  sufficiently  familiar  with  the  bony  pelvis  through  his  obstetri- 
cal reading  to  obviate  the  necessity  of  introducing  even  a  brief  descrip- 
tion of  it  here. 

Pelvic  Peritoneum. 

As  its  name  implies,  this  includes  that  portion  of  the  serous  lining 
of  the  abdomen  which  covers  the  floor  of  the  pelvis  and  invests  more 
or  less  completely  the  contained  organs.  The  peritoneum  covering  the 
anterior  abdominal  wall,  as  traced  in  a  vertical  mesial  section  at  a  point 
an  inch  or  an  inch  and  a  half  above  the  upj^er  border  of  the  symphysis 
pubis,  is  reflected  backward  to  the  fundus  of  the  bladder.  Covering 
the  posterior  surface  of  that  viscus  as  low  as  the  level  of  the  internal 
OS  (and  as  much  of  the  lateral  surfaces  as  lies  behind  the  obliterated 
hypogastric  arteries),  it  crosses  over  to  the  anterior  surface  of  the  uterus, 
which  it  invests,  while  laterally  it  extends  outw^ard  in  a  plane  perpen- 
dicular to  that  of  the  pelvic  brim,  to  be  attached  to  the  lateral  wall  of 
the  cavity,  forming  the  anterior  fold  of  the  broad  ligament :  having 
covered  the  fundus  uteri,  it  descends  on  the  posterior  surface  of  the 
organ  to  a  point  on  the  vaginal  wall  about  an  inch  below  the  utero- 
vaginal junction,  at  the  same  time  extending  laterally  as  the  posterior 
lamina  of  the  broad  ligament.  Finally,  it  is  reflected  from  the  vagina 
to  the  anterior  surface  of  the  second  portion  of  the  rectum,  and  ascends 
to  the  third  part,  which  it  surrounds  completely  (Fig.  67).  Above  this 
point  it  leaves  the  pelvis,  and  need  not  be  traced  farther. 

Besides  investing  the  organs  in  the  manner  described,  the  membrane 


THE  PKLVIC  PERITOSKrM. 


205 


liiu's  the  lateral  walls  nf  tlii'  jx'lvis  and  tlij)s  dnwii  to  cover  the  ]>elvie 
floor,  forming  the  anterior  ami  posterior  ioss<e,  which  are  sc])arate<l  by 
the  broad  ligaments.  The  anterior  is  not  so  deep  as  the  j)osterior,  sinee 
the  ])eritonciiiii  at  the  sides  of"  the  bladder  only  descends  as  low  its  the 
base  of  the  broad  ligament,  while  behind  the  uterus  it  forms  the  pouch 


Diagrrammatic  Representation  of  the  Pelvic  Peritoneum,  as  seen  in  a  mesial  section  fRanney) : 
P,  P,  peritoneum ;  li,  rectum ;  U,  uterus ;  B,  bladder,  distended  ;  S,  symphysis  pubis. 


of  Douglas,  the  bottom  of  which  is  considerably  below  this  level.  Fol- 
lowing Luschka's  teaching,  we  may  regard  the  peritoneum  as  a  sort  of 
diaphragm  dividing  the  pelvic  cavit}-  into  two  portions :  the  one  above 
the  peritoneum  may  be  called  the  peritoneal  space,  while  that  which  is 
situated  below  it  (/.  e.  between  the  peritoneum  and  the  upper  surfaee 
of  the  levator  ani  mu.scle)  is  the  subperitoneal.  The  latter  contains 
most  of  the  connective  ti.ssue  of  the  pelvis  (Fig.  68). 

From  what  has  already  been  said,  it  will  be  inferred  that  portions 
of  the  pelvic  organs  are  devoid  of  a  peritoneal  investment  ;  all  of  the 
organs  are  really  situatetl  in  the  "  ca\'nra  pelvis  subperitoneale,"  although 
the  anterior  surface  of  the  bladder,  the  anterior  aspect  of  the  cervix, 
the  anterior  fornix  vaginre,  and  the  lower  two-thirds  of  the  rectum  are 


206 


THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


the  uncovered  portions  that  lie  in  this  space.  The  peritoneum  is  capa- 
ble of  a  considerable  amount  of  distension,  so  as  to  accommodate  itself 
to  the  variable  size  and  position  of  each  organ  to  which  it  is  attached. 
Thus  it  is  affirmed  by  some  writers  that  the  lining  of  the  anterior 
abdominal  wall  immediately  above  the  symphysis  is  actually  "  stripped 
olf "  by  the  bladder  as  it  rises  in  extreme  distension.  Less  probable 
is  the  theory  of  Josephs,  that,  as  the  viscus  fills,  it  deprives  the  ante- 
rior surface  of  the  uterus  of  a  portion  of  its  serous  covering.^ 

Polk  has  studied  the  changes  in  the  relative  position  of  the  pelvic 
peritoneum  occasioned  by  pregnancy.^  The  principal  alteration  seems 
to  consist  in  the  elevation  of  the  broad  ligaments  above  the  level  which 


Cross-section  of  the  Pelvis,  showing  the  Peritoneal  and  Subperitoneal  Cavities  (Luschka). 

they  occupy  in  the  nulliparous  woman.  Hart  and  Barbour,  reasoning 
from  the  appearances  seen  in  frozen  sections,  maintain  that  "during 
parturition  the  peritoneum  is  drawn  oif  from  the  bladder."  Savage  is 
sceptical  on  this  point.  Without  stopping  to  discuss  a  matter  which  is 
still  sub  judice,  it  may  at  least  be  said  that  the  attachment  of  the 
serous  membrane  to  the  lower  part  of  the  anterior  abdominal  wall 
and  to  the  fundus  and  posterior  surface  of  the  bladder  is  less  inti- 

^ "  Beitrag  zur  iEtiologie  der  Uterns-flexionen  auf  Grund  anatomisclier  TJnter- 
suchung.  u.  Klin.  Beobachtung,"  Beitrag  zur  Geburtsh.  und  GyndJcologie,  Bd.  ii.,  1879. 

^  "  Observations  upon  the  Anatomy  of  the  Female  Pelvis,"  N.  Y.  Med.  Journ.,  Dec, 
1882. 


77//;  I'l'.LVic  ri:iUT()M:vM.  207 

mate  than  ('Isc'wlicrc,  so  tliat  il"  a  separation  or  slri|i|)ii);:;  oil'  o(;ciirrc(l 
it  would  (loiil)tlcss  !)(•  at  tlicsc;  j)oiiits.  'I'lial  (lie  litems  is  over 
depi'ive<l  of  its   periloncal   coveriiii;'  is   iniprdlniMc. 

Tlie  various  attaeliineiits  and  folds  of  tlie  pelvic  j»eritoneiini  have?  been 
described  separately  under  the  name  of  "  litranients"  and  "pouches." 
The  forraor  term  is  not  a  liap|)y  one,  since  the  delicate  meniWrune  in 
(piestion  seldom  if  evei-  has  a  true  lia,amentons  function,  this  heinj^ 
assumed  l)v  the  subperitoneal  layer  of  fibro-nniscular  tissiu;  which 
Savajic  has  described  as  a  platysma  muscle.  The  expression  "false 
liii'aments,"  commonly  emi)loyed  by  anatomists  in  descri])in^  the  ])elvi(' 
ortians,  is  in  itself  an  evidence  that  the  peritoneum  is  not  regartled  as 
atfordino-  much  support  to  the  structures  beneath  it, 

l^ciiiuuino;  anteriorly  as  beibre,  we  notice  in  the  median  line  a  narrow 
fold  of  peritoneum  which  extends  from  the  lunbilicus  along-  the  anterior 
abdominal  wall,  and  is  then  reflected  along  the  urachus  to  the  fundus 
of  the  bladder.  This  is  known  as  the  ligamcntum  snspensorium,  or 
superior  false  ligament.  The  folds  which  extend  outward  from  the 
sides  of  the  organ  constitute  the  lateral  false  ligaments.  Tlu^  utero- 
vesieal  ligament  (or  ligaments)  includes  that  portion  of  the  membrane 
which  stretches  between  the  uterus  and  bladder. 

The  broad  ligaments  are  the  double  folds  of  peritoneum  before  men- 
tioned, which  extend  from  the  sides  of  the  uterus  to  the  lateral  walls  of 
the  pelvis,  dividing  that  cavity  into  two  parts.  They  contain  the 
uterine  appendages  with  their  vessels  and  nerves,  the  vessels  and  nerves 
of  the  uterus,  and  other  important  structures,  all  of  wdiich  have  been 
described.  In  order  to  gain  an  intelligent  idea  of  the  formation  and 
contents  of  the  broad  ligaments,  the  reader  should  forget  for  a  time  the 
unfortunate  term  "  ligament,"  and  recall  the  appearance  of  the  mesentery 
\vith  its  t^vo  laminoe,  between  which  are  the  vessels  and  nerves.  The 
conditions  are  similar :  let  the  Fallopian  tube  represent  a  loop  of  small 
intestine,  and  the  corresponding  broad  ligament  wnll  be  its  mesentery. 
Again  :  imagine  that  there  is  a  double  layer  of  membrane  stretching 
across  the  pelvis,  and  that  the  uterus  has  pushed  its  -way  up  from 
beneath  and  separated  the  laminte,  Avhich  are  elsewhere  closely  approx- 
imated. And  when  we  remember  that  each  layer  of  peritoneum,  as  it 
becomes  folded,  carries  with  it  its  subperitoneal  layer  of  fibro-muscular 
tissue,  the  subject  becomes  greatly  simplified.  It  is  now^  easy  to  under- 
stand that  there  must  be  a  space  between  the  laminae  in  which  run  the 
vessels  and  nerves,  so  that  these  are  subperitoneal  as  well  as  the  organs 
which  they  supply.  When  the  bladder  is  empty  and  the  uterus  is  inclined 
forward,  the  broad  ligaments  run  outward  and  backward,  while  their 
planes  are  tipped  in  such  a  manner  that  their  anterior  surfaces  look 
downward  and  forward.  The  base  of  each  ligament  will  be  rc]>resented 
approximately  by  a  wavy  line,  convex  over  its  external  half,  drawn 


208 


THE  ANATOMY  OF  THE  FEMALE  PELVIC   ORGANS. 


from  the  lateral  border  of  the  uterus  at  the  level  of  the  os  internum 
outward  to  a  point  just  in  front  of  the  sacro-iliac  synchrondrosis  (Fig.  69). 
Its  upper  margin,  corresponding  \\dth  that  of  the  tube,  is  slightly 
concave  near  the  uterus,  from  the  superior  angle  of  which  it  extends  to 
"a  point  on  the  pectineal  line,  situated  in  the  virgin  about  midway 
between  the  sacro-iliac  synchondrosis  and  the  ilio-pectineal  eminence.^' 
Its  inner  attachment  is  along  the  lateral  border  of  tlie  uterus  from 
the  superior  angle  almost  to  the  lateral  fornix  of  the  vagina,  from 
which  it  is  separated  Ijy  a  quantity'  of  loose  connec-tive  tissue  enclosing 
a  venous  plexus.  The  outer  edge  of  the  ligament  is  attached  to  the 
pelvic  wall  "  along  a  line  which  is  situated  betsveen  the  great  sacro- 

FiG.  69. 


Diagram  showing  the  Attachments  and  Relations  of  the  Broad  Ligaments  rRanney) :  P,  P,  pel- 
vic bones ;  Z7,  uterus ;  V,  vagina ;  0,  ovarj' ;  F,  FaUopian  tube ;  B.  L,  broad  ligaments. 


sciatic  notch  and  the  margin  of  the  obturator  foramen,  as  far  doAvn  as 
the  level  of  the  ischial  spine."  According  to  Polk,  as  the  uterus 
enlarges  during  pregnancy  the  bases  of  the  broad  ligaments  are  car- 
ried upward  until  at  term  they  are  almost  on  a  level  with  the  pectineal 
line;  their  upper  borders  are  simultaneously  moved  backT^-ard.  They 
return  to  their  former  positions  after  deliverv. 

The  following  objects  are  suspended  \\'ithin  the  folds  of  the  liga- 
ments :  Along  the  upper  margins  are  the  Fallopian  tubes,  enclosed 
betw^een  the  two  folds  which  are  attached  around  their  distal  extremites, 
where  the  serous  passes  into  the  mucous  membrane.  The  strip  of  peri- 
toneum between  the  tube  and  the  ovary  is  the  mesosalpinx.  As  the 
fimbriated  extremities  do  not  reach  the  pelvic  walls,  the  gaps  are  filled 


Till-:  I'KLVIC  I'EIUTOSIJUM. 


209 


bv  tlu'so-calkHl  inf'iiu(lil)iil<»-|)tlvic  lij^anionts,  which  arc  sini])ly  the  dis- 
tal portions  of  the  upjtcr  inarjiiiis  ot"  tlic  hroad  lijiaiiiciits.  lidow  the 
proximal  vmU  i»l"  the  tubes  are  the  ovarian  ligaments,  at  the  outer  ends 
of  which  arc  the  ovaries.  These  orfrans  arc  includetl  Ix'tween  the  two 
lavcrs,  but  arc  attached  to  the  anterior  and  project  throuj^h  the  j)os- 
terior.'  The  term  raesovarium  is  sometimes  applied  to  a  j)ortioii 
of  the  broad  liirament  just  below  the  attached  border  of  the  ovary.  A 
space  between  the  Ibkls  of  the  mesosalpinx,  between  the  distal  end  oi' 


Diagram  showing  the  Three  Minor  Folds  of  the  Broad  Ligament  (Ranney) :  1.  2.  3.  anterior, 
middle,  and  posterior  folds;  if,  round  ligament:  F,  Fallopian  tube:  O.  ovary:  V.  vagina: 
JJ.  pouch  of  Douglas:  A,  anterior  layer  of  broad  ligament;  P,  posterior  layer:  7>.  reflection 
of  peritoneum  to  bladder:  B,  reflection  to  rectum;  S,  space  containing  muscular  and  con- 
nective tissue,  enclosing  vessels  and  nerves. 

the  ovar}-  and  the  infundibulum,  is  called  bv  Olshausen  ^  the  bursa 
ovarica.  In  the  mesosalpinx  beloAv  the  middle  portion  of  the  tube  is 
the  parovarium.     The   round  ligaments   are  still   lower  down,  more 

^  Reference  has  already  been  made  to  the  assertion  of  some  writers  that  there  is  no 
peritoneum  on  the  posterior  surface  of  the  ovary. 
^  Krankheiten  der  Ovarkn,  Stuttgart,  1S77,  p.  7. 
Vol.  I.— 14 


210        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

internal  than  the  ovaries,  and  lie  in  a  plane  more  anterior  than  the 
organs  already  mentioned  ;  the  view  that  the  ovary  is  situated  in  a 
separate  posterior  fold  of  the  broad  ligament,  the  tube  in  a  middle 
fold,  and  the  roimd  ligament  in  an  anterior,  introduces,  in  the  wri- 
ter's opinion,  an  unnecessary  complication  (Fig.  70). 

In  the  space  bounded  above  by  the  tube  and  below  by  the  round 
ligament  are  the  ovarian  artery  with  its  branches,  the  pampiniform 
plexus,  and  a  dense  network  of  nerves  and  lymj)hatics;  below  this 
region  is  one  quite  free  from  large  vessels.  Near  the  base  of  the  liga- 
ment are  the  uterine  artery  and  venous  plexus,  and  nerves  and  lym- 
phatics as  above.  The  position  of  the  ureters  with  reference  to  the 
broad  ligaments  has  been  made  the  subject  of  much  discussion.  Savage 
affirming  that  they  are  normally  found  between  the  laminse,  which  is' 
denied  by  Garrigues.  As  Polk  has  shown,  in  nulliparae  they  extend 
downward  along  the  lateral  walls  of  the  pelvis,  passing  behind  the  pos- 
terior layers  of  the  ligaments  at  their  points  of  attachment,  and  dip- 
ping down  beneath  the  bases  of  the  same ;  during  pregnancy  the  liga- 
ments may  change  their  positions  and  their  folds  become  expanded, 
while  the  ureters  are  but  little  disturbed,  so  that  the  latter  may 
come  to  be  included  within  them.' 

After  covering  the  posterior  surface  of  the  uterus,  the  peritoneum  dips 
downward  to  cover  the  posterior  vaginal  fornix  and  a  small  portion  of 
the  upper  extremity  of  the  posterior  wall,  and  then  it  ascends  to  the 
rectum.  Two  folds,  however,  cross  over  directly  from  the  uterus, 
extending  backward  and  outward  in  the  shape  of  a  letter  V,  surround 
the  middle  part  of  the  rectum,  and  are  attached  to  the  second  sacral 
vertebra.^  These  are  known  as  the  utero-sacral  ligaments,  or  folds  of 
Douglas,  and  from  their  structure  as  well  as  their  function  they 
approach  more  nearly  to  the  character  of  true  ligaments  than  do  any 
of  the  peritoneal  processes  thus  far  mentioned.  They  contain  a  con- 
siderable amount  of  fibrous  and  smooth  muscular  tissue,  so  that  they 
possess  a  firm,  cord-like  feel.  They  may  be  described  as  fibro-mus- 
cular  bands  enveloped  by  peritoneum. 

Several  well-marked  pouches  exist  in  the  pelvic  peritoneum.  The 
most  important  of  these,  as  noted  in  order  from  before  backward,  are 
the  pubo-vesical,  vesico-abdominal,  utero-vesical,  and  the  recto-uterine, 
or  pouch  of  Douglas.     When  the  empty  bladder  is  in  systole  the  peri- 

'  A  consideration  of  the  supporting  function  of  the  broad  ligaments  belongs  properly 
to  the  article  on  Displacements.  The  writer  does  not  believe  that  they  offer  much 
resistance  to  either  antero-posterior  displacements  or  prolapsus  of  the  uterus.  When 
normal,  they  doubtless  oppose  to  some  degree  lateral  dislocation,  just  as  they  may  cause 
lateroflexion  when  contracted. 

2  We  have  Polk's  statement  to  the  effect  that  during  gestation  the  utero-sacral  liga- 
ments are  elevated  en  masse — not  only  their  uterine  origins,  but  also  their  points  of 
attachment  to  the  bony  pelvis,  so  that  they  meet  the  sacrum  near  the  promontory. 


Tin-:  I'l.Lvic  I'F.inroM'j'M. 


211 


toiiciiiii  ;i[)|)t'ai>  to  lie  rcllcctftl  diicctly  iVnin  tlir  anterior  nlxloiniiial  wall 
to  llii'  iitcnis,  while  a  (liprc.-.-ioii  exists  over  tiie  .site  of  the  Madder  whieh 
has  Ihvii  called  the  iiteru-ahdoiuiiial  ixnieh.  This  cavity,  when  it  exists, 
is   Hlk'tl  witii  coils   of  small   intestine,  which  are  j^rraduully  displaced 


Fiu.  71. 


The  Reflectiniis  and  I'mirhes  of  the  Pelvic  Peritoneum  >  Hodge). 


upward  a.s  the  bladder  becorae.s  distended.  The  vesico-abdorainal 
pouch  is  only  observed  during  di.stension  of  the  bladder ;  its  depth 
varies  according;  to  the  point  at  which  the  .serous  lining  of  the  ab- 
dominal wall  is  reflected.  It  is  always  empty.  The  vesico-uterine 
pouch  is  bounded  in  front  by  the  posterior  surface  of  the  bladder, 
and  behind  l)y  the  anterior  surface  of  the  corpus  uteri.  The  actual 
depth  of  this  fxssa  varies  less  than  that  of  the  others,  because  of  the 
firm  attacliment  of  the  peritoneum  to  the  uterus.  When  the  blad- 
der is  empty  the  bottom  of  this  pouch  is  .separated  by  about  an  inch 
from  the  anterior  cul-de-.«ac  of  the  vagina;  the  entire  pouch  ri.ses  .some- 
what as  the  bladder  fills.  (See  Fig.  71). 

The  pouch  of  Dougla.s  is  the  most  important,  as  well  as  the  largest, 
of  the  serous  culs-de-sac  of  the  pelvis.  Its  shape  and  extent  are  not 
con.stant.  It  is  bounded  in  front  by  tlie  posterior  vaginal  wall  to 
the  extent   of  an   inch,   and    by  the    po.sterior   surface  of  the    supra- 


212        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

vaginal  portion  of  the  cervix,  behind  by  the  anterior  surface  of  the 
middle  third  of  the  rectum,  and  laterally  by  the  utero-sacral  folds.  In 
spite  of  opposing  statements,  the  writer  has  satisfied  himself  by  repeated 
observations  in  both  dead  and  living  subjects  that  Hart  and  Barbour 
are  correct  in  asserting  that,  "  v^hen  the  bladder  is  empty  and  the  unim- 
jji'egnated  uterus  to  the  front,  there  is  small  intestine  in  Douglas's 
'pouch,  excepjt  at  its  very  lowest  part."  The  normal  depth  of  the  pouch, 
as  well  as  its  precise  relation  to  the  posterior  cul-de-sac,  has  been  vari- 
ously estimated.  The  variations  in  depth  may  range  between  twelve 
millimeters  and  three  centimeters.  The  bottom  of  the  pouch  (which 
is  the  lowest  limit  of  the  pelvic  peritoneum)  may  encroach  so  far  upon 
the  space  between  the  rectum  and  vagina  as  to  reach  the  apex  of  the 
perineal  body.^ 

Other  pouches  of  less  importance  might  be  mentioned.  A  depres- 
sion on  each  side  of  the  bladder  is  called  the  paravesical  pouch ;  these 
pouches  may  contain  loops  of  small  intestine  when  the  bladder  is 
emptied  and  the  uterus  lies  well  forward.  The  external  and  internal 
inguinal  pouches,  which  lie  one  on  each  side  of  the  obliterated  hypo- 
gastric artery,  are  more  properly  described  in  connection  with  the  sur- 
gical anatomy  of  inguinal  hernia.  The  reflection  of  the  peritoneum 
along;  the  round  ligament  to  form  the  canal  of  Nuck  has  been  alluded 
to  in  the  section  on  the  round  ligaments. 

Besides  the  disposition  of  the  pelvic  peritoneum  in  the  form  of  small 
pouches,  we  may  regard  the  cavity  as  divided  into  two  fossae — an  anterior, 
lying  in  front  of  the  uterus  and  broad  ligaments,  and  a  posterior,  which 
is  situated  behind  them.  From  ^^'hat  has  already  been  said,  it  will  be 
remarked  that  the  peritoneum  covering  the  anterior  fossa  is  not  so 
firmly  attached  as  that  in  the  posterior  :  this  fact  is  interesting  in 
connection  with  the  theory  of  the  pelvic  segments,  as  will  be  shown 
subsequently.  The  posterior  fossa  has  been  further  subdivided  by 
Polk  into  two  portions — an  upper,  which  lies  above  the  level  of  the 
utero-sacral  ligaments,  and  includes  two  triangular  surfaces  called  by 
him  the  "retro-ovarian  shelves,"^  and  a  lower,  which  is  Douglas's 
pouch.  The  boundaries  of  each  shelf  are :  in  front,  the  base  of  the 
corresponding  broad  ligament,  internally,  the  utero-sacral  ligament 
of  the  same  side,  and  externally,  the  wall  of  the  pelvis.  The  upper 
portion  of  the  posterior  fossa  communicates  with  the  lower  through 
the  space  which  exists  between  the  utero-sacral  ligaments.  In 
nulliparge  the  most  dependent  point  in  the  peritoneal  lining  of 
the  pelvis  (excepting,  of  course,  the  bottom  of  Douglas's  pouch) 
nearly  always  lies  above  a  horizontal  plane  intersecting  the  middle  of 

1  Pirogoff  figures  a  section  of  a  pelvis  in  which  it  descends  as  low  as  the  ostium 
vaginfe. 

^  So  named  because  the  prolapsed  ovaries  frequently  rest  upon  them. 


Tin:  I'Ki.vic  ri:nrr<>si:rM.  '21 M 

the  .<vin|>liysis  in  iVoiit  and  tiic  |>i>iiit  of  tlic  iinioii  of  the  tliii'(l  aii<l 
tuiirtli  saiTiil  vcrtcltra-  Ix-liiiid.  In  tlic  |»rctiiiaii(  woiiiaii,  liowcvcr,  llic 
fldiii's  ol'  l)ittli  lo.vsa'  arc  lai.-cd  (tlic  jtostcrini-  nid.-t  iioticcaMy),  until  at 
tlu'  st'vciitli  nidiitli  tlic  rctiM-ovariaii  .-^licivcs  occupy  a  liif^iicr  level  than 
the  pelvic  hrini,  wliile  at  th(^  same  lime  the  posterior  fossa  is  contracted 
l)V  rca--on  of  the  ehan}>"e  in  the  external  attaelim<nt.-  of  the  liroad  liga- 
iiients.  I'A-eii  Doiiiilas's  jumicIi  is  slightly  elevated  above  its  ordinary 
level  (l*olU).     Till'  chanj;es  in  the  anterior  fossa  arc  less  strikinu'. 

PiJAtTlcAL  Dkductions. — The  |)eritoiieum  possesses  a  jiceuliar 
interest  for  the  s;ynec()lo<:;ist,  because  it  not  only  clothes  the  peKic 
oriians,  but  from  its  sensitiveness  to  irritation  receives  and  transmits 
iiiHnm Illations  Irom  them,  h'atal  j)eritonitis  has  ceased  to  be  regarded 
iLS  the  natural  eonseinienee  of  injury  to  the  serous  lining  of  the  ]«']- 
vis,  but  localized  iuHanimation  is  sutKeiently  common  and  tlei>lorable 
in  its  ultimate  consequences.  These  limited  inflammatory  foci  are 
most  common  in  two  localities,  and  for  different  reasons — around 
the  distal  extremities  of  the  tubes  and  ovaries,  through  the  direct 
extension  of  inflammation  of  the  lining  of  the  genital  tract,  and 
along  the  bases  of  the  broad  ligaments,  as  the  concomitant  (or  result) 
of  so-called  cellulitis.  Remembering  how  the  coils  of  small  intestine 
descend  into  the  pelvis,  so  that  their  serous  covering  is  in  direct  con- 
tact with  that  of  the  pelvic  cavity,  it  is  evident  that  a  peritonitis  may 
remain  strictly  localized,  and  yet  may  result  in  the  formation  of 
adhesions  which  will  impair  the  functions  of  several  organs.  When 
the  la|)arotomist  boasts  at  the  i)resent  day  that  peritonitis  is  a  rare 
complication,  he  refers  to  a  general  affection  of  the  serous  membrane. 
Some  organs  are  only  loosely  covered  by  peritoneimi ;  to  others  it 
is  closely  adherent.  This  distinction  is  not  unimportant,  since  injury 
to  the  serous  coat  of  the  uterus,  for  example,  is  a  more  serious  matter 
than  if  a  tear  in  the  peritoneal  covering  of  the  bladder  is  involved, 
both  as  regards  hemorrhage  and  subsequent  inflammation. 

It  is  desirable  that  the  reader  should  rid  his  mind  of  the  idea  that 
the  so-called  broad  ligaments  are  "  ligaments  "  in  the  sense  that  they 
furnish  much  sujiport  to  the  uterus :  they  rather  serve  to  steady  it  and 
ojjpose  lateral  deviation  of  the  organ.  Doubtless  their  most  important 
function  is  to  suspend  the  uterine  appendages  and  to  support  the  net- 
work of  vessels  that  ramifv  between  its  folds.  Cicatrices  in  either  lig- 
ament produce  lateroflexion,  a  form  of  displacement  exceedingly  resist- 
ant to  treatment.  Tearing  of  the  folds — an  accident  which  is  not  un- 
common in  separating  adhesions  during  laparotomy  or  as  a  result  of 
too  great  traction  upon  the  pedicle  of  an  ovarian  or  tubal  tumor — is 
followed  by  an  obstinate  hemorrhage,  wdiicli  it  is  difficult  to  control 
Ijccause  of  the  situation  of  the  l)leeding  ]ioints  at  the  bottom  of  the 
pelvis.     Temporary  compression  by   means  of  long  forceps,  or  pres- 


214        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

sure  exerted  through  the  vaginal  fornix  by  means  of  a  firm  tampon, 
is  sometimes  useful  when  it  is  impossible  to  ligate  the  oozing  sur- 
faces. 

It  is  impossible  to  discuss  the  subject  of  sub-  and  intraperitoneal 
hsematocele  here ;  contrary  to  the  opinion  advanced  by  Savage,  the 
peritoneum  is  capable  of  being  separated  from  the  subjacent  tissues  to 
such  an  extent  as  to  allow  of  the  formation  of  large  extravasations 
beneath  it.  This  is  particularly  noticeable  during  pregnancy ;  hence 
the  possibility  of  making  gastro-elytrotomy  a  strictly  subperitoneal 
operation.  Recent  writers  have  expressed  doubt  as  to  whether  pelvic 
abscess  is  ever  confined  to  the  cellular  tissue — i.  e.  they  believe  that  it 
is,  nearly  always,  of  tubal  origin.  The  fact  that  such  abscesses  often 
lie  wholly  beneath  the  peritoneum  should  negative  this  theory. 

The  pouches  formed  by  the  pelvic  peritoneum  possess  much  prac- 
tical interest.  The  bottom  of  the  vesico-uterine  pouch  lies  so  far  above 
the  anterior  vaginal  fornix  that  it  is  not  exposed  to  injury  during 
operations  in  this  region ;  the  distance  of  the  peritoneum  from  the 
fornix  will  be  appreciated  during  the  preliminary  steps  of  vaginal 
extirpation  of  the  uterus,  as  it  is  necessary  to  separate  the  bladder 
entirely  from  the  uterus  before  the  serous  membrane  is  reached.  It 
is  accordingly  advised  to  open  Douglas's  pouch  and  to  retrovert  the 
uterus  through  it  before  dividing  its  peritoneal  attachments  anteriorly. 
Unless  there  is  an  unusually  low  dip  of  the  vesico-uterine  fold,  it  will 
not  be  endangered  in  any  ordinarv"  operation  on  the  cervix,  short  of  high 
amputation.  The  bottom  of  Douglas's  pouch,  on  the  contrary,  lies 
normally  only  one-third  of  an  inch  above  the  tip  of  the  examining 
finger  when  introduced  into  the  posterior  fornix  ;  this  distance  may  be 
diminished,  not  only  by  the  pressure  of  morbid  growths,  the  fundus  of 
a  retroverted  uterus,  exudations,  etc.,  but  by  the  existence  of  an  abnor- 
mally deep  dip  of  the  membrane,  as  in  the  condition  described  by 
Pirogoif,  where  it  covered  the  posterior  vaginal  wall  almost  as  low  as 
the  vulvo-vaginal  outlet.  Less  significance  is  attached  to  the  opening 
of  the  peritoneal  cavity  through  the  posterior  fornix  now  that  the 
principles  of  drainage  are  better  understood.  Note  that  the  middle  por- 
tion of  the  rectum  is  only  partially  covered  by  peritoneum  (anteriorly), 
although  sufficiently  to  be  affected  by  inflammations  and  adhesions  of 
that  membrane. 

The  utero-sacral  ligaments  are,  as  before  stated,  essentially  folds  of 
peritoneum  strengthened  by  fibro-muscular  tissue ;  whether  peritonitis 
or  cellulitis  is  the  inflammation  most  common  in  them  is  an  open 
question.  Probably  both  the  serous  and  fibrous  tissues  are  involved 
in  nearly  every  case  of  so-called  "  parametritis  posterior."  They  are 
commonly  contracted  in  epithelioma  of  the  cervix,  even  where  the 
broad   ligaments  are  not  involved,  and  complicate  the  final  steps  of 


I'lu.vic  ciiSM-jTivi-:  Tissvi:.  215 

va<;inal   hystiTt'ctoiny.     Tlic  siipixirtin;^-   fiiiKlion  of  llic-i-  IuuhIs   will 
1)1'  (list'iisscd   later. 

As  rcji'ards  the  iiiiicli-vcxctl  ([iic-tinii  nf  the  iTl;iti\c  l'rci|iiciicv  of" 
peri-  and  parametntis,  it  may  be  addcnl  that  tlie  aiiatomieal  evidences 
ail'  ;;i"eatly  in  fiivor  of  tlie  former,  as  will  a])pear  to  the  reader  who 
eoiisiders  tin-  various  sources  (»f  infection  to  which  the  peritoneum  is 
exposed.  The  results  of  recent  .studies  in  tidjal  ])atholojiv  have  led  to 
a  ('hauLic  of  vii'ws  on  the  subject  of  pelvic  inHainiaation.' 

Pelvic  Connective  Tissue. 

There  are  few  subjects  in  the  whole  range  of  normal  and  pathological 
anatomy  about  which  so  much  has  been  written — and  blindly  ^^•ritten 
— as  that  of  the  cellular  tissue  of  the  female  pelvis.  It  is  the  bete 
noire  of  the  student  and  the  stumbling-block  of  the  more  mature. 
Instead  of  taking  a  rational  view  of  the  matter  and  remembering  that 
connective  tissue  possesses  exactly  the  same  structure,  appearance,  and 
functions  in  whatever  region  of  the  body  it  may  be  found,  nine  men 
out  of  ten  approach  the  study  of  the  pelvic  areolar  tissue  in  somewhat 
the  same  .spirit  as  they  begin  that  of  the  brain — with  the  idea  that  they 
are  about  to  grapple  with  a  thing  sui  generis,  the  thorough  ma.stery  of 
which  will  be  a  formidable  task.  Doubtless  writers  on  gynecology  are 
responsible  partly  for  this  notion,  since  they  have  been  somewhat  dis- 
posed to  adapt  anatomical  facts  to  pathological  theories,  instead  of 
taking  that  broader  view  of  the  subject  which  can  alone  prevent  one 
from  falling  into  error,  Avhether  of  theory  or  of  practice. 

The  pelvis  is  not  an  independent  region  of  the  body,  neither  do  its 
various  tissues  exist  nnder  different  conditions  from  the  same  tis.sues 
in  other  portions  of  the  body.  In  considering  the  pelvic  areolar  tissue 
as  a  whole  instead  of  referring  to  it  under  the  description  of  each 
organ,  we  not  only  gain  a  clear  idea  of  its  relations  to  the  separate 
organs,  but  are  able  to  appreciate  better  its  close  continuity  with  the 
entire  fibrous  framework  of  the  body.^  Although  this  continuitv 
may  not  always  be  as  clearly  marked  as  in  the  case  of  the  mem- 
brane which  has  just  been  studied,  it  is  none  the  less  present,  as  will 
be  seen. 

Connective  tissue,  whether  it  appears  in  the  form  of  areolar  or 
lymphoid  tissue,  cartilage,  or  bone,  always  has  the  same  office — "  to  con- 
nect and  support  the  other  tissues,  performing  thus  a  passive  mechanical 

^  Comp.  paper  by  the  ■writer  on  "The  Exaggerated  Importance  of  Minor  Pelvic 
Inflammations"  ( X.  Y.  Med.  Joiirn.,  May  15,  1886 1 ;  also  paper  by  Prof.  W.  M.  Polk 
in  the  X  Y.  Med.  Record,  Sept.,  1886. 

-  Freund  ( G>/na/:nlof/ii)rhe  Klinil:.  Strasbur?,  1885)  ha.s  complicated  the  subject  by 
describing  the  connective  tissue  around  the  various  organs  by  separate  names.  He 
refers  to  the  '"  paracystium,"  "  paracolpium,"  "  paraproctium,"  etc. 


216        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

function."  ^  As  viewed  in  the  pelvis,  it  appears  under  tv\^o  varieties  or 
systems  •?  1.  As  a  loose  tissue  which  is  distributed  apparently  in  a  most 
irregular  manner  around  and  between  organs,  and  between  the  layers 
of  the  broad  ligaments,  where  it  serves  to  support  the  blood-vessels, 
the  folds  of  peritoneum,  etc. ;  2.  As  firm,  well-defined  laminae  or 
planes  which  enter  into  the  formation  of  the  pelvic  floor,  and  together 
constitute  the  "  pelvic  fascia."  The  latter  will  be  described  with  the 
pelvic  floor. 

Considered  in  its  entirety,  all  of  this  connective  tissue  forms  the 
middle  layer  of  the  three,  which  begins  above  with  the  peritoneum;  it 
may  be  traced  from  before  backward  in  a  vertical  median  section,  just 
as  was  done  with  the  peritoneal  layer,  beneath  which  it  lies  throughout. 
Passing  down  the  anterior  abdominal  wall  below  (that  is,  anterior  to)  the 
peritoneum,  as  low  as  the  posterior  aspect  of  the  pubic  symphysis,  it. 
stretches  across  to  the  anterior  surface  of  the  bladder,  as  the  pubo- 
vesical, or  anterior  true  ligaments  of  that  organ.  Immediately  behind 
the  pubes  it  contains  a  quantity  of  adipose  tissue  (retro-j)ubic  fat), 
which  has  a  triangular  outline  in  mesial  sections  of  the  pelvis,  the 
bladder  being  empty.  The  position  of  this  pad  of  fat  varies  in  different 
attitudes  of  the  body  :  when  the  patient  is  in  the  genn-pectoral  posture 
it  sinks  downward  and  forward,  so  as  to  be  below  {i.  e.  above)  the 
symphysis.  There  is  a  certain  amount  of  areolar  tissue  in  the  space 
bounded  by  the  lower  part  of  the  posterior  vesical  wall  in  front  and 
the  cervix  uteri  and  upper  third  of  the  anterior  vaginal  w^all  behind. 
This  tissue  contains  a  venous  plexus,  and  serves  to  unite  the  vagina  to 
the  base  of  the  bladder.^  When  the  latter  is  empty  this  "  vagino- 
vesical process  "  is  all  that  intervenes  between  the  peritoneum  and  the 
anterior  cul-de-sac. 

The  lower  two-thirds  of  the  anterior  vaginal  wall  are  so  firmly 
attached  to  the  urethra  by  an  intermediate  layer  of  connective  tissue 
that  it  is  possible  to  separate  them  only  by  careful  dissection.  While 
the  supravaginal  portion  of  the  cervix  is  surrounded  by  a  quantity  of 
loose  fibrous  tissue,  on  the  fundus  and  anterior  surface  of  the  uterus, 
as  well  as  beneath  the  vesico-uterine  fold,  there  exists  only  the  delicate 
subperitoneal  layer  before  described  (the  "platysma"  of  Savage). 
Laterally,  however,  the  tissue  is  again  well  marked,  where  it  extends 
outward  between  the  folds  of  the  broad  ligaments.  This  same  pla- 
tysma,  composed  as  it  is  of  fibrous,  elastic,  and  smooth  muscular  tis- 

1  Schiifer,  Essentials  of  Histolor/j/,  p.  30. 

2  The  loose  cellular  tissue  of  the  pelvis  has  been  divided  by  some  authorities  into 
two  "processes"— a  "pubo-sacral,"  including  the  median  portion  of  the  layer,  extend- 
ing from  the  symphysis  pubis  to  the  sacrum,  and  a  "  utero-iliac,"  which  comprises  the 
fibres  extending  outward  from  the  lateral  borders  of  the  uterus  to  the  pelvic  wall 
between  the  folds  of  the  broad  ligaments. 

^  It  is  the  "  parametric"  tissue  of  Virchow. 


rF.LVir  royyFJTivr.  tissue. 


217 


sue,   is    ivricctoil  on   !<»    llii-   liilxs,    roiiiid    liji,aiM(.'iits,   iit('r(i-s;i<'r:il,   ami 
ovarian  liiiuincnts,  loi-miiii;  tlicii"  siipcrlicial   layer. 

It  is  cliilicnlt  to  understand  how  some  authorities  can  deny  the  |»res- 
eueo  of  lihro-inuseuhn*  tissue  in  the  hroad  lli^anieuts.  Reasoniuj^-  IVoui 
analo^ry,  tiie  [)rosenco  of  such  a  rich  \aseular  area  as  that  which  lies 
between  these  folds  of  peritoneum  |)resu])p()ses  the  existence  of  no 
inconsiderable  ([uantity  of  such  tissue  iu   (he  iuuuediate  neighborhood 

I'lc.  7-2. 


Mesial  Section  of  the  Pelvis,  cutting  at  junction  of  Broad  Ligament  and  Uterus  :  a,  vagina,  with 
its  walls  separated;  b.  bladder;  c,  symphysis;  d,  broad  ligament;  e,  ovary;/.  Fallopian 
tube.    (Hart  and  Barbour). 

of  the  blood-vessels.^  This  alone  Mould  be  a  convincing  proof,  even 
if  it  were  not  possible  to  trace  Avith  ease  distinct  bands  of  fibres  which 
are  continuous  with  the  general  connective  ti.-^sue  of  the  pelvis.  Gue- 
rin's^  idea,  that  the  ti.ssuc  between  the  folds  of  the  ligaments  has  no 
connection  with  the  rest,  is  not  tenable,  any  more  than  if  it  Avas 
affirmed  that  the   included   vessels   M-ere  independent  of  the  general 

^  The  reader  will  also  remember  that  each  fold   of  peritoneum  lias  its  own  platvs- 
ma  layer. 

'^  rhierin,  '"  Sur  la  Structure  des  Liuaiiients  larges,"'  (/iiinptes  n')t(lii)>,  1879,  p.  13G4. 


218         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

pelvic  circulation.  In  point  of  fact,  the  application  of  the  term  ''  liga- 
ments "  to  these  reduplications  of  the  peritoneum  is  only  justified  by 
the  presence  in  them  of  a  strong  fibrous  and  muscular  framework,  as 
was  shown  in  the  case  of  the  sacro-uterine  bands.  Without  such  a 
framework  they  could  not  even  furnish  proper  support  to  the  vessels 
and  nerves,  not  to  speak  of  the  uterine  appendages.  In  short,  the 
connective  tissue  of  each  broad  ligament  is  the  ligament  itself ;  the 
peritoneal  folds  constitute  simply  a  thin  veil  which  is  thrown  over 
the  former,  but  which  does  not  increase  its  strength.^  The  tissue  in 
question  enters  the  broad  ligament  from  various  sources.  The  super- 
ficial muscular  stratum  of  the  uterus  contributes  numerous  delicate 
fibro-elastic  bands ;  others  are  reflected  from  the  external  layers  of  the 
tubes  and  round  ligaments.  The  vessels  carry  with  them  their  own  sup- 
porting tissue  and  the  peritoneal  folds  have  their  thin  elastic  substra- 
tum. The  areolar  tissue  seems  to  be  most  abundant  at  the  bases  of  the 
ligaments,  where  it  blends  ^vith  the  mass  already  referred  to,  which  sur- 
rounds the  cervix  uteri  and  roof  of  the  vagina,  filling  the  interval 
between  these  and  the  neck  of  the  bladder.  The  richness  of  the  blood- 
and  lymph-supply  of  these  parts  was  noted  in  another  place.  The 
practical  importance  of  these  facts  will  be  evident  in  connection  with 
the  pathology  of  cellulitis. 

Proceeding  backward  from  the  broad  ligaments,  we  observe  a  thin 
subperitoneal  layer  on  the  posterior  surface  of  the  uterus ;  it  is  not  so 
intimately  united  to  the  subjacent  muscle  as  it  is  over  the  fundus  and 
anterior  aspect  of  the  organ,  so  that  a  certain  amount  of  separation 
of  the  peritoneum  is  possible.  Between  the  rectum  and  the  posterior 
vaginal  wall  there  is  a  stratum  of  areolar  tissue  which  extends  down- 
ward as  low  as  the  apex  of  the  perineal  body,  establishing  a  loose 
connection  between  the  two  canals  (recto-vaginal  process).  The 
upper  portion  of  this  tissue  surrounds  the  supravaginal  portion  of  the 
cervix  and  the  posterior  fornix.  As  in  the  vesico-uterine  pouch,  it 
separates  the  fornix  from  the  peritoneal  cavity.  The  entire  thick- 
ness of  the  tissues  intervening  between  the  latter  cavity  and  the 
vagina  is  estimated  at  not  over  a  third  of  an  inch.  The  opinion 
has  already  been  expressed  that  the  "  folds  of  Douglas,"  or  utero- 
sacral  ligaments,  are  true  ligaments,  consisting  of  bands  of  fibrous 
tissue  enclosing  elastic  and  muscular  fibres,  the  latter  being  derived 
from  both  the  uterine  and  the  vaginal  walls.  Their  direction  is  such 
(upward  and  backward)  that  they  would  lie  almost  in  a  line  with  the 

^  The  unstriped  muscular  tissue  of  the  broad  ligaments  is  thickest  near  the  borders 
of  the  uterus.  As  we  trace  them  outward  both  the  fibrous  and  muscular  bundles 
decrease  in  number  and  size,  until,  on  reaching  the  pelvic  wall,  they  have  almost 
entirely  disappeared.  Note  that  the  bases  of  the  broad  ligaments  are  in  contact  with 
the  lateral  culs-de-sac  of  the  vagina,  except  when  the  former  are  elevated  during 
pregnancy  (Eanney). 


PELVIC  COXM-CTIVJ-:   TISSUE.  219 

anterior  wall  oi"  the  vaiiiiia  if  it  wi-re  exteiideil  iKiekward  (Fi^.  7."J).' 
Luselika"  well  described  liolli  the  sti'iietiire  and  the  innetions  of  these 
tolds  w  hi'n  he  applied  to  them  the  name  nuiscii/it.s  retractor  uteri.  The 
"  pnl)o-saeral  "  [»i-oeess  ol"  eonneetive  tissne  terminates  in  a  thin  layer 
which  separates  the  rectnni  from   the  saernm. 

A  description  of  Konig's  method  ol"  dcmonstratinti'  the  coiitimiitv 
of  the  suhjieritoneal  eonneetive  tissne  by  means  of  injections  of  air  or 
fluids  belongs  more  properly  to  the  snbjeet  of  ex})erimental  patholo;i,y. 
His  results,  as  snnunarized  by  IJandl,  were  briefly  as  follows  :  On  inject- 
ing- water  into  the  space  between  the  folds  of  one  broad  li<rament,  the 
site  of  the  injection  being  near  the  upper  edge  of  the  ligament,  it  flrst 
extended  i^)ut\\ard  to  the  pelvic  wall,  then  entered  the  iliac  fossa  beneath 
the  peritoneum  ;  from  this  ])oint  it  made  its  way  both  upward  along  the 
anterior  abdominal  wall,  and  downward  along  the  wall  of  the  true  pel- 
vis. If  injected  below  the  base  of  the  ligament,  however,  anterior  to, 
and  a  little  to  one  side  of,  the  utero-eervieal  junction,  it  first  spread  in 
a  lateral  direction,  and  later  distended  the  vcsico-utcrine  subperitoneal 
space ;  it  then  made  its  "svay  beneath  the  peritoneum  covering  the 
anterior  surface  of  the  supravaginal  cervical  segment  and  the  poste- 
rior aspect  of  the  bladder,  and  ran  along  the  round  ligament  to  the 
internal  ring,  turned  to  the  left  to  follow  the  line  of  Poupart's  liga- 
ment, and  terminated  in  the  iliac  fossa.  If  fluid  is  introduced  pos- 
terior to  the  base  of  the  ligament,  it  first  infiltrates  the  corresponding 
half  of  the  posterior  fossa,  then  extends  to  the  iliac  fossa,  and  event- 
ually reaches  the  anterior  abdominal  wall  as  before.^ 

Practical  Deductions. — Great  importance  has  been  attached  to 
the  manner  of  distribution  of  the  pelvic  cellular  tissue  in  connection 
with  the  study  of  ])arametritis  and  abscess-formation.  For  details  the 
reader  must  consult  special  works.  In  some  localities  it  is  evident 
that  an  inflammatory  process  may  be  limited  to  this  tissue ;  in  others 
(notably  in  the  broad  ligaments)  it  is  difficult  to  conceive  how  the 
peritoneum  can  fail  to  be  involved.  The  experiments  of  Konig  and 
Bandl,  in  w'hich  fluid  or  air  was  injected  into  the  cellular  tissue  of 
the  pelvis  in  order  to  determine  the  course  taken  by  collections  of  pus, 
explain  the  "pointing"  of  abscesses  in  the  perineum,  in  the  inguinal 
region,  or  even  as  high  up  as  the  umbilicus.  Konig  holds,  briefly,  that 
an  exudation  between  the  folds  of  the  broad  ligament  eventually  makes 
its  way  to  the  floor  of  the  pelvis  along  the  ilio-psoas  muscle,  M-hile 

^  F(ir  an  ingenious  explanation  of  the  action  of  these  ligaments,  consult  Fosters 
paper  on  "The  Mechanical  Action  of  Pessaries,"'  Am.  Gyn.  Tt-ans.,  1881.  Comp.  Fos- 
ter's diagram,  reproduced  by  Ranney  {op.  cit.,  fig.  6). 

-  Op.  cit.,  p.  o()l. 

'Elaborate  experiments  of  the  above  character  have  been  reported  by  Schlesinger 
(Med.  Jahrb.  der  K.  K.  Geselkchaft  d.  Aei-zte  in  Wien,  Heft  1-2,  1878).  See  also  Bandl, 
op.  cit..  pp.  109-1]  4. 


220        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

a  collection  of  pus  forming  near  the  side  of  the  cervix  follows  the 
course  of  the  cellular  tissue  at  the  lateral  borders  of  the  uterus, 
then  passes  beneath  the  inguinal  canal  along  the  round  ligament, 
and,  reaching  Poupart's  ligament,  turns  backward  and  outward  to 
reach  the  iliac  fossa.  Rupture  of  a  pelvic  abscess  into  the  peritoneal 
cavity  is  fortunately  rare,  spontaneous  perforation  into  the  vagina, 
rectum,  or  bladder  being  much  more  common.  The  danger  of  hem- 
orrhage in  incising  an  abscess  through  the  fornix  is  not  imaginary, 
and  should  render  the  thermo-  or  galvano-cautery  preferable  to  the 
knife. 

Subacute  inflammation  of  the  cellular  tissue  is  a  common  result  of 
puerperal  lesions,  especially  laceration  of  the  cervix.  However  we 
may  difPer  in  regard  to  the  character  and  significance  of  the  indura- 
tions which  are  found  at  the  bases  of  the  broad  ligaments  in  cases  of 
deep  laceration  of  the  cervix,  we  must  admit  that  they  do  exist,  and 
that  they  radiate  directly  outward  from  the  angle  of  the  tear.  Dr. 
Emmet  has  attached  great  importance  to  their  detection  by  palpation 
through  the  vaginal  fornix,  and  to  the  advisability  of  endeavoring  to 
promote  their  absorption  by  means  of  hot-water  injections  and  local 
applications  before  the  operator  can  safely  or  successfully  repair  the 
lacerated  cervix.  He  is  also  inclined  to  regard  utero-sacral  cellulitis 
as  a  consequence  of  injury  to  the  cervix — a  sequence  which,  from  the 
indirect  relation  of  the  parts  involved,  is  by  no  means  clear. 

While  the  writer  has  no  desire  to  dwell  upon  his  personal  views 
regarding  the  treatment  of  chronic  cellulitis,  he  cannot  avoid  the 
temptation  to  propose  to  the  reader  the  consideration  of  the  follow- 
ing questions  in  the  light  of  the  foregoing  anatomical  studies :  Are 
small  cicatrices  or  strictly  localized  thickenings  in  the  serous  or 
cellular  tissue  of  the  pelvis  capable  of  obstructing  the  circulation 
over  a  sufficient  area  to  cause  chronic  engorgement  of  the  uterus  and 
its  appendages?  Does  the  constricting  action  of  hot  vaginal  injec- 
tions directly  affect  the  vessels  not  contiguous  to  the  fornix  ?  Does 
the  entire  pelvic  circulation  feel  their  influence,  or  is  ansemia  produced 
in  one  locality  at  the  expense  of  hypersemia  in  another?  Let  the 
reader  recall  what  has  been  said  regarding  the  extent  and  continuity 
of  the  venous  plexuses,  and  answer  for  himself.^ 

One  more  question  may  be  permitted  :  Is  it  in  the  power  of  hot- 
water  injections,  iodine,  and  glycerin-tampons  to  act  through  the 
vaginal  fornix  in  such  a  manner  as  to  cause  the  absorption  and  dis- 
appearance of  firm,  non-vascular  cicatricial  bands,  which  may  be  situ- 
ated w^ithin  the  pelvis   from   a  third  to  half  an  inch  from  the  spot 

^  It  is  claimed  that  in  these  questions  we  are  dealing  with  known  clinical  facts.  No 
one  denies  the  local  hsemostatic  and  astringent  action  of  hot  water ;  reference  is 
made  to  its  power  to  modify  the  circulation  at  distant  points. 


PELVIC  CONNECTIVE  TISSUE. 


roaclicti  l)y  the  inicrtiuii  ov  ;i|i|>li<':i(iim  ?  Whatever  dircciioii  our 
anat<»mi("il  speculations  may  take,  eliiiieally  we  shall  never  re<rret 
the  atlo|>tion  ol'  the  routine  ])raetiee  of  renardinji;  with  suspicion  all 
evidenei'S,  whetlier  sul)jeetive  ol"  ohjeetivi',  (»t"  f'orniel"  periuterine 
indaniMiatioii,  and  oi"  resti-ainiutr  our  ardor  operandi  aeeordin<:lv. 

Sinee  the  utero-saeral  folds  of  peritoneum  are,  bv  reason  (jf  their 
contained  connective  tissue  and  mode  of  attachment,  true  ligaments,  it 
seems  advisable  to  studv   their 

normal  and    pathological  action  '"''■ 

here.  This  V-shaped  process, 
which  can  usually  be  distinctly 
felt  through  the  posterior  for- 
nix, is  attached  to  the  uterus 
just  above  the  isthmus,  in  such 
a  line  that  it  forms  with  the 
anterior  vaginal  wall  \\hat  Fos- 
ter has  ai)tly  called  a  "  support- 
ing beam  " — the  two  structures 
opposing  each  other  and  retain- 
ing the  uterus  (which  lies  in  the 
middle  of  the  beam)  in  its  nor- 
mal position.  That  the  liga- 
ments contain  a  sufficient 
amount  of  muscular  fibre  to 
justify  Luschka  in  calling 
them  the  *'  rctractores  uteri " 
is  proved  clinically,  not  only 
bv  the  state  of  tension  which 
is  observed  in  them  during  a 
vaginal  examination,  but  also 
by  the  fact  that  they  often  dis- 
tinctly relax  under  the  influence  of  an  antesthetic.  The  writer  has 
affirmed,  as  the  result  of  clinical  and  anatomical  observations,  that 
the  diagnosis  of  "  thickening  of  the  utero-sacral  ligaments "  (para- 
metritis posterior)  is  often  ba.sed  ujjon  a  supposed  prominence  or 
tension  of  these  cords  which  is  entirely  normal.  Every  gynecologist 
must  have  noticed  how  moderate  anteflexion,  due  to  apparent  shorten- 
ing of  the  ligaments,  has  been  practically  eliminated  after  the  ])atient 
was  anfesthctized. 

True  cicatricial  contraction  of  the  utero-sacral  folds  (whether  as  the 
result  of  cellulitis  or  peritonitis,  or  of  a  combination  of  the  two  con- 
ditions) leads  to  anteflexion  and  vesical  irritation,  the  latter  symptom 
being  one  of  the  most  trying  with  which  the  gynecologist  has  to  deal. 
The  futility  of  expecting  to  accomplish  much  l)y  the  use  of  anteflexion 


iJiagram  of  Model  designed  to  show  the  suiif.ort- 
ing  action  of  the  Anterior  Vaginal  Wall  and 
the  Utero-sacral  Ligaments  (Foster* :  A,  B,  C, 
D,  two  elastic  bands  intersecting  at  the  point 
of  attachment  of  the  uterus  {U),  which  is  fast- 
ened to  them  by  a  pivot  (P) ;  S,  s>'mphysis  pnbis 
fastened  fh-mly  tn  block,  as  is  also  the  sacrum 
(.S) :  r,  uterus  rendered  movable  in  all  direc- 
tions by  the  elastic  bands;  T'.  vagina,  repre- 
sented by  a  piece  of  rubber  tubing:  L,  rubber 
bantl  representing  utero-sacral  ligaments. 


222        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

pessaries  will  be  apparent  to  any  one  who  views  the  displacement  even 
from  a  purely  mechanical  standpoint,  since  the  problem  is  not  to  ele- 
vate the  fundus,  but  to  relieve  backward  traction  on  the  organ. 
Neither  does  dilatation  of  the  cervical  canal  for  the  purpose  of 
overcoming  the  mechanical  obstruction  (with  or  without  the  intro- 
duction of  a  stem  pessary)  fulfil  the  main  indication,  which  is  to 
stretch  the  shortened  ligaments.  How  far  it  is  possible  to  accomplish 
this  clinically  by  means  of  tampons,  massage,  etc,  we  shall  not 
attempt  to  decide  here. 

Pelvic  Floor. 

Synonyms. — Pelvic  diaphragm ;  Lot.,  diaphragma  pelvis  ;  Fr., 
plancher  pelvien ;   Ger.,  Beckenboden. 

Definition. — By  the  pelvic  floor  we  understand  the  ensemble  of  the 
soft  parts  which  close  the  outlet  of  the  pelvis.  Strictly  speaking,  this 
definition  includes  several  of  the  organs  already  described  (the  rectum, 
vagina,  and  bladder),  as  well  as  the  serous  and  fibrous  layers  which 
have  just  been  mentioned.  We  shall  limit  it  to  the  actual  diaphragma 
pelvis^ — i.  e.  the  levatores  ani  muscles,  with  the  layers  of  fascia  above 
and  below  them,  the  perineal  body,  with  the  muscles  and  fascise  enter- 
ing into  its  composition,  the  ischio-rectal  fossse,  and  the  integument  cov- 
ering the  whole. 

In  order  to  possess  a  clear  idea  of  the  diaphragm  we  may  imagine 
that  we  are  looking  down  upon  it  from  above,  after  having  removed 
the  uterus  and  broad  ligaments,  together  with  the  peritoneum,  and 
cleared  away  as  much  of  the  loose  connective  tissue  as  suffices  to  expose 
the  underlying  fascia.  We  have  now  to  consider  from  above  down- 
ward— that  is,  from  within  outward — the  following  distinct  lamiuse : 
Two  layers  of  fascia,  a  superior  (recto-vesical)  and  an  inferior  (anal), 
between  which  are  the  levatores  ani ;  below  these  is  a  space  occu- 
pied posteriorly  by  the  lower  end  of  the  rectum,  with  its  muscles, 
and  a  quantity  of  fat  (ischio-rectal  fossa),  and  corresponding  anterior- 
ly to  the  cavity  between  the  two  layers  of  the  triangular  ligament. 
Still  lower  are  the  inferior  boundaries  of  these  spaces — behind,  the 
obturator  fascia;  in  front,  the  anterior  layer  of  the  triangular  liga- 
ment. Next  comes  the  deep  layer  of  the  superficial  perineal  fascia ; 
and  lastly,  the  superficial  layer  and  the  integument. 

We  may  group  the  component  parts  of  the  pelvic  floor  into  a  superior 
and  an  inferior  layer,  the  latter  including  the  parts  ordinarily  exposed 
in  a  dissection  of  the  perineum,  which  may  be  studied  best  from  below. 
The  superior  or  deeper  parts  will  first  be  considered. 

^For  exhaustive  details  refer  to  Hart's  monograph,  "  The  Structural  Anatomy  of 
the  Female  Pelvic  Floor,"  Edinburgh,  18S1. 

'■^  Under  this  term  German  writers  refer,  as  a  rule,  to  tlie  levatores  ani  alone. 


THE  PEI.VK'  FiJtOi:. 


09:^ 


Altlioiiiili  till'  :iii:iii;:ciiitiif  of  tin-  pt-lvic  liiscia  is  <'X|)Iaiiic(l  in  all  <>!' 
the  staiulani  works  mi  general  aiiatmiiy,  tlic  <l('scri|>tiniis  nearly  always 
liave  rctrn'iicc  to  tlic  male  pelvis,  in  which  the  relatimis  oC  the  |)arts 
are  ciiiiipai-atiNclv  sini|)le.  In  the  female  the  Moor  ix  pierced  hy  tlie 
vauiiia,  so  that  a  i'iini|)licati<»n  i-  tinis  introduced  which  renders  a  sep- 
arate description  of  the  |»arts  necessary.     The  pelvic  I'u-seia,  a.s  viewed 

Fid.  74. 


Fascia  of  Pelvic  Floor  (Savage):  B.  bladder:  T'.  vagina;  B,  rectum;  P,  pubic  symphysis;  S, 
sacrum ;  a,  fascia  covering  psoas  muscle ;  b,  obturator  fascia ;  c,  ilio-pubic  line ;  d,  reflection 
of  fascia  on  to  the  rectum,  vagina,  and  bladder:  e,  posterior  portion  of  pelvic  fascia  cover- 
ing sacral  vessels  and  nerves;  /,  iliac  fascia,  covering  iliac  vessels;  ^,  gluteal  vessels;  h, 
ischiatic  vessels;  i,  internal  pudic  vessels;  k,  obturator  vessels. 


from  above,  is  seen  to  be  attached  laterally  to  the  ]K'lvic  brim  ;  ante- 
riorly, its  line  of  attachment  extends  downward,  following:  the  oritjin 
of  the  obturator  muscles,  and  terminates  near  the  lower  border  of  the 
symphysis  pubis.  As  it  crosses  the  obturator  foramen  the  fascia  becomes 
attached  to  the  membrane  which  covers  that  openintr.  Posteriorly,  it 
is  adherent  to  the  spine  of  the  i.sehium,  beJiind  which  point  it  is  con- 
tinuous with  a  thin  lamina  that  covers  the  pyriformis  mu.scle  and  sacral 
plexus  (fascia  of  the  pyriformi.s) ;  the  latter  separates  the  sacral  plexus 


224 


THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


from  the  iliac  vessels,  branches  of  the  latter  piercing  the  pelvic  fascia.^ 
The  attachment  of  the  pelvic  fascia  is  clearly  indicated  by  a  tendinous 
band  ("white  line")  which  extends  from  the  spine  of  the  ischium  to 
the  lower  portion  of  the  symphysis.  From  this  line  springs  the  recto- 
vesical fascia,  which  is  now  regarded  as  the  direct  continuation  of  the 
pelvic,  instead  of  the  obturator,  fascia,  as  is  still  affirmed  by  many 
anatomists.^  The  recto-vesical  process  arises  as  above  mentioned,  ex- 
tends downward  and  in^vard,  lying  upon  the  upper  surface  of  the  cor- 


Muscles  of  Pelvic  Floor  (Savage; :  B,  neck  of  bladder;  T,  vagint^'^  It,  rectum;  P,  symphysis 
pubis;  C,  coccyx;  S,  sacrum:  A,  acetabulum;  1,  anterior  vesical  ligaments;  2,  pubo-coccyg- 
eal  portion  of  levator  ani;  3,  obturator-coccygeal  portion ;  4,  ilio-pubic  line  of  the  latter; 
5,  ischio-coccygeal  portion ;  7,  pyriform.is  muscle  ;  8,  obturator  muscle. 

responding  levator  ani,  and  unites  in  the  median  line  with  the  fascia  of 
the  opposite  side.  The  fascial  diaphragm  thus  formed,  Avhich  separates 
the  pelvic  from  the  perineal  space,  is  perforated  by  two  slits,  the  vagina 
and  the  rectum.     It  is  firmly  attached  to  the  walls  of  these  canals,  and 

1  Comp.  Quain's  Anatomy,  vol.  i.  p.  326 ;  Ellis,  Dissections,  p.  546 ;  Carrington,  Dis- 
sections, pp.  145  and  160-167  ;  Heath,  Practical  Anatomy, '^p.  266-268. 
^Carrington,  op.  cit,  p.  161 ;  also  Quain,  op.  cit.,  p.  326. 


Tin:  rKLVic  FLonn. 


22o 


sends  off  from  its  iiiidcr  >iirliic('  lihrmis  >li(:itlis  wliidi  >nn-<»iiii<l  ;iinl 
follow   the   tiilx'S  (jowinviirtl. 

The  rt'ctal  ,-licatli  cuvcrs  the  lower  three  iiielie~  of  the  l»o\vcl,  j^rad- 
uallv  disapiK-ariiii;  toward  the  amis;  it  lies  immediately  over  the 
superior  hemorrhoidal  vessels.  The  vairiiia  also  has  an  eiiveloj)e, 
whieh  mav  he  traeed  alonjj;  the  1iil)e  lo  it>  lower  end,  w  iiei'e  it  ix'oomcs 
lost  in  the  deep  j)erineal  fascia  {'.').  It 
covers  the  va<>iiial  plexuses  and  con- 
stitutes the  external  layer  (tf  tiie  va- 
ginal wall. 

The  bladdi'r  also  receives  su]>port 
from  the  same  source,  the  anterior 
true  ligaments  being  formed  by  two 
processes  which  extend  from  the  back 
of  the  pubes  (the  anterior  attachment 
of  the  fa.scia)  to  the  neck  of  the  blad- 
der ;  between  these  special  processes 
the  recto-vcsical  fascia  is  said  by  El- 
lis to  descend  to  the  triangular  liga- 
ment of  the  urethra,  of  which  it  forms 
the  posterior  layer.^  The  lateral  liga- 
ments of  the  bladder  are  formed  by 
fascial  bands  which  arc  attached  to 
the  postero-latcral  border  of  the  vesi- 
cal base.  The  rectum  has  also  two 
lateral  ligaments  derived  from  the 
same  fascia,  which  are  attached  ex- 
ternally to  the  ischial  spines,  and  op- 
pose lateral  displacement  of  the  gut. 

'-  ,  .  J^  transverse    perineal    muscle:    3,    bulb   of 

On    removing    that    portion  of   the       vagina;  4,  muscle  of  perineal  septum. 

recto-vesical    fascia    of    both    sides 

which  covers  the  floor  of  the  pelvis,  bv  detaching  it  along  the  entire 
length  of  the  white  line  externally  and  from  its  attachments  to  the 
pelvic  organs  internally,  the  subjacent  muscular  stratum  will  come 
into  view  (Fig.  75).  This  consists  of  two  pairs  of  muscles,  the 
coccygei  and  the  levatores  ani,  the  former  being  comparatively 
unimportant  in  this  connection.  The  coccygei  (levatores  coccygis, 
ischio-coccygei  of  Savage)  are  two  thin,  triangular  muscles  which 
spring  from  the  upper  portions  of  the  ischial  spines,  and  by  a  few 
slips  from  the  lesser  sacro-sciatic  ligaments,  and  pass  inward,  gradually 
expanding  into  broad,  thin  laminte  that  are  attached  to  the  lateral  bor- 
ders of  the  lower  segment  of  the  sacrum  and  to  the  anterior  surface  and 

'  Denied  by  Carrington  (Manwd  of  Dissections,  p.  165),  who  intiists  that  the  deep  layer 
is  formed  by  the  obturator  fascia. 
Vol.  I. — 16 


2  PW4-   S 

Perpendicular  tran.-verse  Section  of  Pelvis 
through  middle  of  Vagina  (Savage):  V, 
vagina,  showing  posterior  wall :  O,  ischio- 
rectal fossa,  filled  with  fat;  T,  ischial  tube- 
rosity; i?,  inferior  pelvic  space;  />,  recto- 
vesical fascia,  covering  upper  surface  of 
levator  ani;  C,  fascia  covering  lower  sur- 
face of  levator  ani ;  X,  olnurator  fascia ;  P, 
posterior  aponeurosis  of  perineal  septum; 
.1/,  anterior  aponeurosis  of  same ;  S,  deep 
layer  of  superficial  perineal  fascia;  1, 
cross-section  of  right  crus  clitoridis,  in- 
cluding   erector    muscle :     2,    superficial 


226 


THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


borders  of  the  coccyx.  Their  inner  (pelvic)  surfaces  are  covered  by- 
special  layers  of  fascia  continuous  with  the  recto- vesical.  The  upper 
surface  of  the  left  coccygeus  is  in  contact  with  the  rectum,  which  it 
partially  supports.  The  lower  surfaces  rest  upon  the  glutei  maximi 
and  the  lesser  sacro-sciatic  ligaments ;  in  front  are  the  posterior  borders 
of  the  levatores ;  behind,  the  pyriformis  muscles,  separated  from  the 
pair  under  consideration  by  vessels  and  nerves. 

The  levatores  ani  have  such  extensive  origins  and  insertions  that 
each  muscle  is  divided  by  Savage  into  t^vo  separate  portions,  pubo- 
and  obturato-coccygeal.  The  coccygeus  muscle  he  includes  with  the 
levator  under  the  name  of  the  ischio-coccygeus.  Each  levator  arises 
in  front  from  the  posterior  aspect  of  the  pubes  near  the  symphysis 
(pubo-coccygeus),    behind,   from    the  lower  and  inner  surface  of  the 


Fig.  77. 


-    v..  7 


lis,  /  I  - 


"A  lii 


:-^*il  tli'ikt^ 


''WiiiJ'fii''' 

/ 


5  6 

Attachment  of  the  Muscular  Floor  of  the  Pelvis  to  the  Bladder,  Vagina,  and  Rectum  (Savage) : 
B,  bladder;  V,  vagina;  It,  rectum;  1,  pubo-coccygeus;  2,  otaturato-coccygeus ;  3,  ischio- 
coccygeus;  4,  ilio-pubic  attachment  of  muscle;  5.  coccygeal  attachment;  6,  median  raphe ; 
7,  Arcus  tendineus  of  Luschka,  aponeurotic  fibres  reflected  to  bladder. 

ischial  spine,  and  between  these  origins  from  the  "  white  line "  that 
represents  the  point  of  division  of  the  pelvic  fascia.  It  is  also  con- 
nected by  fleshy  slips  with  the  obturator  fascia  and  the  posterior  layer 
of  the  triangular  ligament.  The  anterior  fibres  may  form  a  separate 
bundle,  an  interval  existing  between  them  and  the  rest  of  the  muscle ; 
these  extend  downward  and  inward  contiguous  to  the  posterior  layer 


77//;  I'l.l.Vir  FLnon.  L'-J7 

of  the  tri:iii^iil:ii'  li^Miiiciit,  :iiiil  unite  in  the  niediiiu  line  nf  the  |ie|\'is 
with  tlie  ••<>nc-|Kiii(|iiiii  |»()ii  inn  ol'  the  o|i|(u~ite  muM-le.  'Ihe  iM-ethi:il 
and  vaii;iiial  slips  perforate  the  inns<Mihir  ilia|>hra;j;in  hei-e,  and  feeeivo 
.sli|)s  tVoin  it  ;  Ix-hind  the  vagina  the  internal  Hl»fes  of  ojtpo.-ite  nins<'le.s 
meet  and  Mend  with  the  deep  tran>\'er-e  p<iineal  inn>ele~  in  the  peri- 
neal body.  The  |)f(»lnn<iati(>ns  ot"  the  pnl)u-eoee\ j^^ens  nti  the  sides  of 
the  vajfiiia  and  ni'ethra  convspoud  to  Santorini's  iniiseles  ( levatorcs 
prostatjo)  in  the  male.'  The  j)o.sterior  ]»ortion  (I''ii:.  77)  of  the  piiho- 
c<Hvvireiis  (eorrespoiidin<i;  with  the  middle  portion  of  other  anatomists) 
unites  with  its  fellow  to  surround  the  lower  end  of  the  rectum,  whieh 
it  suspends  as  it'  in  a  sliuu",  and  Mends  with  the  external  (and,  to 
Some  extent  also,  with  the  internal)  sphinet<'r.  The  most  posterior 
of  the  fibres  unite  behind  the  rectum  in  a  median  raphe  whicii  termi- 
nates at  the  end  of  the  coccyx.  The  posterior  part  of  the  levator  (the 
obturator  coccviii-eus  of  Savaire)  meets  its  fellow  in  the  raj)he  behind 
the  rectum,  and  I)oth  are  inserted  into  the  sides  of  the  la.st  two  eoe- 
cvgeal  vertebne,  below  tlu-  insertions  of  the  eoecygei  (i.schio-coccygei). 

From  the  ahove  it  will  Ik'  evident  that  the  levatores  ani  form  a  thick 
septum  across  the  jK'lvic  outlet,  the  general  shape  of  whicli  is  concave  ; 
this  septum  at  its  }>eripherv  has  bony  attachments  extending  around 
the  brim  of  the  pelvis,  while  its  centre  has  no  fixed  su])port.  In  the 
median  line  it  is  weakened  by  the  presence  of  the  vaginal  slit,  which 
defect  is  obviated  to  some  extent  l)y  the  fact  that  the  vaginal  walls  are 
normally  in  close  apposition,  and  that  the  canal  cuts  the  ])elvic  floor  at 
an  angle  of  al)out  sixty  degrees  (Hart  and  Barbour).  The  firm  attach- 
ment of  the  muscular  diaphragm  to  the  genit< (-urinary  organs  is  an 
important  factor  in  connection  with  the  maintenance  of  their  proper 
positions. 

A  thin  layer  of  fascia  covers  the  under  surface  of  the  levator;  it 
arises  from  the  pelvic  brim  below  the  origin  of  the  muscle,  and  is 
attached  to  the  obturator  fascia,  while  in  the  median  lifie  it  blends  Avith 
the  opposite  lamina  and  is  attached  to  the  rectum  and  vagina  in  the 
same  maimer  as  the  recto-vesical  fascia,  although  it  is  much  less  devel- 
oped than  the  latter.  Anteriorly,  it  is  attached  to  the  posterior  laver 
of  the  triangular  ligament.  It  is  in  immediate  relation  below  Mith 
the  fat  which  fills  the  iscliio-rectal  fossa.  A  description  of  the  obtu- 
rator iascia  does  not  really  belong  here,  since  it  merely  covers  the  inner 
surface  of  the  <jbturator  muscle,  and  thus  forms  the  outer  wall  of  the 
ischio-rectal  space. 

After  removing  the  layers  above  mentioned  there  remain  onlv 
the  superficial  structures  which  chtse  the  pelvic  outlet.     The  ischio- 

'  Note  that  Savage's  description  of  the  insertion  of  the  pnbo-coccvgeus  is  pecnliar, 
in  that  he  represents  the  fibres  as  running  downward  and  backward,  rather  tlian  down- 
ward and  inward. 


228         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

rectal  fossse  do  not  need  a  special  description,  since  their  anatomy  is 
the  same  as  in  the  male.  The  perineal  body,  on  the  contrary,  is  a 
structure  peculiar  to  the  female. 


The  Perineal  Body.^ 

Synonyms. —  dr.,  Tzepi'uacov -,  Led.,  perinseum;  Fr.,  perinee ;  Ger., 
Damm ;  It.  and  -S)^.,  perineo. 

Between  the  lower  ends  of  the  rectum  and  vagina  is  a  somewhat 
pyramidal  space,  formed  by  the  divergence  of  the  two  canals  that  have 
been  described  as  lying  in  close  contact  as  low  as  an  inch  and  a  half 
above  the  anus.  This  space  is  filled  by  a  mass  of  fibro-muscular  tissue, 
which  is  attached  not  only  to  the  anterior  wall  of  the  rectum  and  the 
posterior  wall  of  the  vagina,  but  also  to  the  pelvic  floor.  Its  dimen- 
sions are  variable,  depending  not  only  upon  the  muscular  development 
of  the  individual,  but  upon  the  amount  of  adipose.  It  is  common  to 
represent  it  in  mesial  sections  as  a  perfect  triangle.  It  is  highly 
desirable  that  these  diagrammatical  figures  should  cease  to  be  repro- 
duced in  modern  textbooks,  to  mislead  the  inexperienced  reader  and  to 
give  him  false  ideas  of  the  aims  of  gynecological  surgery.  IS^ow  that 
the  "  keystone"  theory  of  the  perineum  has  been  rejected  by  all  thought- 
ful men,  the  inaccurate  representations  of  the  supposed  keystone  should 
not  be  retained  as  the  exuvice  of  a  discarded  error.  The  perineal  body 
is  neither  a  triangle  nor  a  pyramid,  but,  as  we  learn  from  a  careful 
study  of  the  region  both  in  the  living  female  and  in  frozen  sections, 
it  is  irregularly  quadrilateral  in  form ;  ^  sometimes  it  has  almost  the 
shape  of  a  gourd,  the  neck  of  which  corresponds  to  the  "  apex "  of 
the  triangle,  as  formerly  described.^ 

The  quadrilateral  shape  of  the  perineum  is,  as  Foster  has  shown  by 
careful  measurement,  largely  the  result  of  muscular  action,  which  draws 
the  body  forward,  causing  a  prominence  near  the  ostium  vaginse  that 
forms  the  anterior  angle  of  the  square.  T^vo  sides  of  the  square  rest 
thus  against  the  vaccinal  wall,  a  third  looks  toward  the  rectnm,  and 
the  fourth  represents  the  space  between  the  posterior  vulvar  commis- 
sure and  the  edge  of  the  anus.  If,  as  the  same  writer  states,  through 
weakness  of  the  muscles  attached  to  the  perineal  body,  it  is  not  drawn 
forward  in  the  usual  manner,  it  may  present  but  a  single  surface  ante- 
riorlv,  and  then  it  has  the  triangular  shape  usually  figured.  As  before 
stated,  its  dimensions  are  variable.  Its  upper  limit — or  rather  the 
point  at  which  the  rectum  and  vagina  begin  to  diverge — is  about  an 

^  For  literature  refer  to  Hart  and  Barbour,  and  to  Eanney's  paper  on  "  The  Female 
Perineum  "  (N.  Y.  Med.  Journ.,  July  and  Aug.,  1882). 

-  Foster,  "Topograp.  Anat.  of  Uterus,  etc.,"  Am.  Journ.  Obstet.,vo].  xiii.,  1880. 
^  "The  cucurbit  of  an  alembic"  (Garrigues,  Am.  Journ.  Obst,  April,  1880). 


THE  J'i:i:im:al  nonv.  229 

inch  ;iii(l  a  hall'  trmii  the  aiiii~.  Vlir  prc-ciicr  of  :i  thick  JaNcr  nf 
adipost'  ill  a  liit  siihjci-t  will  nf"  cDursc  increase  the  distaiK-e  hetweeii 
its  ajji'x  ami  the  surl'acc  ol'  the  intetiiinient.  The  transvei>>e  nieas- 
urenient  is  an  incli  and  a  hall",  the  antero-po.sterior  from  three-quar- 
ters ot"  an  inch  to  an  ineJi.  Its  relations  have  already  been  mentioned. 
Ant(M-it)r  to  it  lie  the  vaj2;ina,  i)eliiiid,  the  rectum  and  anus,  laterally, 
fat  ;  lu'low,  the  intei;unient  of  the  perineal  space,  above,  the  lower  end 
of  the  lihrous  sej)tuiii  iinitiui;' the  vaii;inal  and  rectal  walls.  The  entire 
body  lies  below  a  horizontal  plaue  passing;  through  the  subpubie  liga- 
ment in  front  and  the  tip  of  the  coccyx  behind. 

Hitherto  we  have  i'ollowed  the  dissection  of  the  pelvic  floor  from 
above.  The  })erineal  body  is  best  understood  by  adopting  the  usual 
order  described  in  manuals  of  dissection.  Unfortunately,  there  is 
much  confusion  as  to  the  exact  meaning  of  the  term  "  perineum," 
nearly  all  of  the  works  on  anatomy  defining  it  as  the  entire  lozenge- 
shaped  space  which  corresponds  to  the  pelvic  outlet.  Others  divide 
this  space  into  an  anterior  and  a  posterior  perineum,  the  latter  includ- 
ing the  anus  and  the  ischio-rcetal  fosste,  the  former,  the  parts  included 
between  the  symphysis  and  pubic  rami  as  far  backward  as  an  imagi- 
nary transverse  line  joining  the  tuberosities  of  the  ischium.  "  The  true 
perineum  of  the  female,"  adds  a  writer,  after  making  the  above  divis- 
ion, "  is  between  the  posterior  commissure  of  the  labia  and  the  anal 
orifice."  ^  The  only  satisfactory  way  out  of  the  difficulty  is,  as  Hart 
and  Barbour  suggest,  to  keep  always  before  the  mind  the  idea  of  a 
perineal  body,  of  Avhich  the  "  perineum  "  of  the  anatomists  is  merely 
the  ''skin  over  the  base."^ 

In  reviewing  briefly  the  anatomy  of  this  region  reference  will  be 
made  to  certain  structures  closely  related  to  it  which  have  already  been 
mentioned  in  connection  with  the  external  genitals.  Having  removed 
the  integument,  not  only  over  the  perineum  proper,  but  over  the  entire 
urethral  triangle,  the  snjjerficial  fascia  w'ill  be  exposed.  This  may  be 
separated  intc*  two  layers — a  subcutaneous,  Avhich  consists  of  fine  trabec- 
ulae  of  fibrous  tissue  enclosing  masses  of  fat  and  branches  of  the  super- 
ficial perineal  and  hemorrhoidal  vessels  and  nerves,  and  a  deep  layer, 
which  is  of  considerable  importance.  The  latter  is  attached  along  the 
anterior  edges  of  the  pubic  and  ischiatic  rami  ^  almost  as  far  back  as 
the  tuberosities.  It  is  limited  posteriorly  by  the  transversus  perinei 
muscles,  around  Avhich  it  turns  to  become  continuous  with  the  subpubic 
fascia  (anterior  layer  of  the  triangular  ligament,  perineal  septum  of 
Savage).  The  lower  edge  of  the  perineal  septum,  which  is  strengthened 
by  the  attachment  of  the  deep  layer  of  fascia,  is  called  the  ischio-jiori- 

'  Heath,  Practical  Anatomi/,  p.  173.  ^  Hart  and  Barbour,  op.  cit.,  p.  38. 

'  Savage  describes  an  "  abdominal  portion,"  which  is  attached  to  Poupart's  ligament 
(op.  cit.,  p.  13). 


230        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

neal  ligament  by  Savage,  who  describes  it  as  "  an  extremely  resisting 
aponeurotic  band  attached  by  its  outer  ends  to  the  rami  of  the  ischi- 
um, somewhat  in  front  of  their  tuberosities.  They  are  confounded,"  he 
adds,  "  in  the  structure  of  the  perineal  body."  The  perineal  septum, 
as  described  and  figured  by  Savage,  is  best  understood  by  a  reference  to 
the  figures.  This  fascia  can  be  traced  directly  into  the  labia  majora, 
and  through  them  to  the  external  inguinal  rings,  to  the  edges  of 
which  it  is  attached,  forming  on  each  side  the  '' pudendal  sac"  {sao 
darto'ique)  before  described,  in  which  the  terminal  fibrils  of  the  round 
ligaments  are  found. 

On  clearing  away  the  tissue  above  mentioned,  which,  with  the  integ- 
ument and  superficial  fascia,  is  intimately  related  to  the  base  of  the 
perineal  body,  the  so-called  perineal  muscles  will  be  exposed,  as  well 
as  the  "  perineal  septum,"  or  anterior  layer  of  the  triangular  lig- 
ament, in  recent  nomenclature.  The  latter  is  comparatively  a  weak 
structure  in  the  female,  because  of  the  manner  in  which  it  is  en- 
croached upon  by  the  urethra  and  vagina.  The  muscles  which  are 
immediately  connected  with  the  perineal  centre,  as  it  is  sometimes 
called,  are  the  bulbo-cavernosi,  transversus  perinei,  sphincter,  and 
levatores  ani  (pubo-coccygeal  portions).  The  transverse  perineal  ves- 
sels and  venous  plexuses  will  be  exposed  with  the  muscles. 

The  bulbo-cavernosi  blend  posteriorly  with  the  perineal  body ;  encir- 
cling the  vaginal  bulbs  and  vestibule,  each  divides,  according  to  Henle, 
into  three  slips,  one  of  which  may  be  traced  to  the  posterior  surface 
of  the  bulb,  another  to  the  lower  surface  of  the  corpus  cavernosum 
clitoridis,  while  the  third  is  lost  in  the  mucous  membrane  of  the  ves- 
tibule. The  function  of  these  muscles  is  not,  as  is  frequently  stated, 
to  contract  the  vaginal  outlet  (which  office  is  performed  by  the  anterior 
portion  of  the  levator  ani),  but  to  compress  the  bulbs.  The  trans- 
versus perinei  are  sometimes  divided  into  two  layers,  a  superficial 
and  a  deep,  separated  hf  the  anterior  layer  of  the  triangular  liga- 
ment. They  appear  almost  invariably  in  actual  dissections  as  pale, 
indistinct  slips,  which  spring  from  the  rami  of  the  ischium  and  ante- 
rior layer  of  the  triangular  ligament,  and  are  lost  in  the  perineal  body. 
The  anal  sphincter,  which  has  been  described,  blends  anteriorly  with 
the  muscles  above  mentioned ;  some  of  its  peripheral  fibres  are  appa- 
rently continuous  with  those  of  the  bulbo-cavernosi.  The  pubo- 
coccygeus  (anterior  portion  of  the  levator  ani),  as  viewed  from  below, 
lies  deeper  than  the  preceding  muscles  (i.  e.  above  them),  as  it  is  behind 
the  perineal  septum  (Fig.  78).  It  encircles  the  vagina,  and  its  inner 
fibres  curve  inward  behind  that  canal  to  enter  the  perineal  body  behind 
the  lower  edge  of  the  septum.  When  traced  farther  backward  they  sur- 
round the  rectum  in  a  similar  manner  between  the  two  sphincters,  and 
blend  with  the  terminal  fibres  of  the  longitudinal  layer  of  the  rectum. 


77//;  i'i:i:/.\i:a/,  iuidy 


TM 


The  crcctnrcs  cliidfidis  arc   iii>t  j)i-()|)crl\    iiK-liidcd  in  tlii-   (lisscftinii 
ami   arc  dcscrilx'd   with   the  clitoris. 

Ivcmoviiin'  the  hiilltn-cavcnutsi  and  the  vaiiinal  hnlli.-,  which  rest 
M|)(ti»  llic  antcrinr  hncr  of  the  t I'ianiiidar  litzanicnt,  the  latter  is  seen 
to  he   [>ci'l(>ratcd    lt\    lnanche-   ol"  the    piidie  aileric-  and    nerves  an<l   1)V 

Fifi.  78. 


Perineal  Septum,  posterior  view  (Savage):  S,  posterior  surface  of  .symphysis:  U.  urethra;  7, 
vagina;  1,  jiubic  attachment  of  bladder;  2,  pubic  attachment  of  levator ani  (pubo-coccyg- 
eus):  3,  line  of  attachment  of  obturato-coccygeus;  -1,  pudic  vein;  .'».  urethro-pubic  plexus 
of  veins;  6,  posterior  surface  of  .septum ;  7,  median  portion  of  pubo-coccygeus,  entering 
perineal  body  at  lower  edge  of  septum. 


the  coaimunicatiiijr  veins  wliieh  extend  from  the  bulbs  and  clitoris 
to  the  vesical  plexuses.  When  the  layer  itself  is  detached,  the  follow- 
intr  structures  are  exposed  :  The  urethra,  surrounded  l)y  tlie  conijiressor 
urethras ^  of  Guthrie,  the  constrictor  vagintc  of  some  authors;^  the  deep 
transversus  perinei,  the  vulvo- vaginal  glands,  internal  pudic  vessels 
and  nerves,  dorsal  vein  and  nerve  of  the  clitoris,  and  artery  of  the 
bulb.  The  two  former  muscles  are  described  by  Pleatli  as  forming  a 
fignre-of-8  around  the  urethra  and  vagina,  being  attached  anteriorly  to 
tlie  posterior  aspect  of  tlie  pubic  arch,  and  entering  the  perineal  body 
behind.     Behind  the  above  structures  lies  the  deep  layer  of  the  tri- 

'  Ellis.  Trans.  Roy.  Med.-Chlr.  Soc,  vnl.  xxxix.,  ISoG. 

^  Why  not  include  these  two  nmscles  in  one  as  ihe  sjdiinoter  vaginse  of  Liischka? 


232         THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

angular  ligament,  belonging  to  the  pelvic  fascia,  which  was  studied 
from  above. 

The  vascular  and  nervous  supply  of  the  urethral  triangle  may  be  dis- 
missed in  a  few  words,  since  it  presents  no  special  points  of  difference 
in  the  two  sexes.  We  are  most  concerned  here  with  the  vessels  and 
nerves  of  the  perineal  region.  The  arteries  spring  from  the  internal 
pudics,  which,  after  re-entering  the  pelvis  through  the  lesser  sacro- 
sciatic  foramina  (each  artery  being  accompanied  by  two  veins  and  a 
nerve),  skirt  the  outer  edges  of  the  ischio-rectal  fossse,  ascend  the  pnbic 
rami,  perforate  the  posterior  layer  of  the  triangular  ligament,  and  con- 
tinue to  ascend  between  the  two  layers  until  within  a  short  distance  of 
the  symphysis,  where  each  terminates  in  the  artery  of  the  corpus  caver- 
nosum  and  the  dorsal  artery  of  the  clitoris.  The  inferior  or  external 
hemorrhoidal  arteries  of  the  pubic  are  tw^o  or  more  small  branches 
which  leave  the  main  vessel  in  front  of  the  tuberosity,  cross  the 
ischio-rectal  fossa,  supply  the  external  sphincter  and  the  posterior 
part  of  the  levator  ani,  and  terminate  by  anastomosing  with  the 
vessels  of  the  opposite  side  beneath  the  skin  around  the  anus  and 
in  the  superficial  perineal  fascia.  The  superficial  perineal  branch 
arises  in  front  of  the  hemorrhoidal,  pierces  the  deep  perineal  fascia, 
crosses  the  transversus  perinei  muscle,  and  extends  forward  beneath  the 
superficial  fascia  to  the  vulva.  It  sends  deep  branches  to  the  surround- 
ing muscles,  and  superficial  twigs  to  anastomose  with  those  from  the 
hemorrhoidal  arteries.  The  transverse  perineal  branch  perforates  the 
posterior  layer  of  the  triangular  ligament,  and  follows  the  course  of 
the  transversus  perinei  muscle  inward,  where  it  divides  into  branches 
that  anastomose  with  those  of  the  opposite  side  at  the  perineal  centre 
beneath  the  deep  layer  of  the  superficial  fascia.  It  may  send  branches 
to  the  corresponding  vaginal  bulb  and  gland  of  Bartholin.  The  veins 
of  the  perineal  region  communicate  freely  with  one  another  and  with 
the  hemorrhoidal  and  labial  plexuses,  as  well  as  with  the  bulbs;  they 
accompany  their  respective  arteries  and  terminate  in  the  pudic  veins. 
The  lymphatics  unite  w^ith  the  vessels  from  the  external  gejiitals  to 
enter  the  inguinal  glands. 

The  perineal  body  is  supplied  exclusively  by  branches  of  the  pudic 
nerve;  the  pudendal  branch  of  the  small  sciatic  may  send  a  twig 
which  enters  the  superficial  perineal  fascia.  The  inferior  hemorrhoidal 
branch  of  the  pudic  accompanies  the  vessels  of  the  same  name  and  has 
a  similar  distribution  ;  the  superficial  perineal  branches  supply  the 
vestibular  area,  the  labia,  and  integument  covering  the  base  of  the 
perineal  body,  communicating  with  the  hemorrhoidal  branch.  The 
deep  perineal  nerve  accompanies  the  superficial  vessels  and  supplies 
the  labia,  vaginal  bulbs,  and  glands,  sending  special  twigs  to  the 
perineal  and  urethral   muscles. 


Till'.    rh/UXh'AL    lloDY. 


233 


I'^'oiii  this  hricf  accniiiil  of  1  lie  ,-ti'iicliircs  ill  iiniiicdiatc  rdalioii  with 

the  periii(':ii  Ixidy  it  will    he  seen  that,  aside   i'v the  support  wliich  it 

pves  to  the  anterior  rectal  wall,  its  principal  otlice  si'cins  t<»  be  to  i()i"ni 
a  point  (Tapj)!!/  for  the  niusclcs  and  fascia-  which  have  hccn  iiicntioncd 
as  constitutinji;  the  siipcrlicial  jxn'tioii  of  the  jx-lvic  fioitr,  and  tliat  tlie 
oidy  way  in  which  it  can  be  said  to  fnrnisii  support  to  the  internal 
litMiital  oriians  is  tiiroiii!;li  its  connection  with  the  flooi-.  'J'hat  its 
relation  with  the  deeper  strnetures  is  not  pai'ticiilarly  intimate  will  be 
inferred  iroin  the  fact  that  it  receives  only  a  few  of  the  more  internal 
fibres  of  the  ])nbo-eoccy*>ei.  Its  base,  on  the  other  hand,  is  closelv 
connected  with  the  snperfieial  portion  of  tiie  floor,  espeeially  with  the 
stronu;  ischio-perineal  ]ii;ament,  which  in  parturition  bears  the  brunt  of 
the  expulsive  force  during-  the  emerirenee  of  the  child's  head  (Fig.  79). 

Fig.  79. 


— -.—  3 


Relations  of  the  Muscular  Floor  of  the  Pelvis  to  the  Presentation  at  the  Last  Stage  of  Parturi- 
tion :  1.  upper  margin  of  vuf^'iiial  ring;  2,  isehio-pcrincal  ligament  and  superficial  trans- 
verse mu<cle  :  :i.  their  attachments  to  the  tuberosities  of  the  ischium  ;  4,  lower  part  of  the 
pubo-  and  obturato-coccygeus  muscles ;  p,  perineal  body ;  a,  anus. 

^^"ant  of  .space  forbids  our  entering  upon  a  discussion  of  tlie  interest- 
ing suljject  of  the  structural  anatomy  and  physics  of  the  pelvic  floor, 
which  have  been  so  admirably  treated  by  the  Edinburgh  authors,  from 
whom  we  have  borrow^ed  freely.  It  may  be  stated,  briefly,  that,  accord- 
ing to  Dr.  Hart's  theory,^  the  floor  may  be  divided  into  two  segments, 
a  pubic,  including  the  bladder,  urethra,  anterior  vaginal  wall,  and  peri- 
toneum covering  the  bladder,  and  a  sacral,  made  up  of  the  rectum, 
perineal  body,  and  posterior  vaginal  wall.  Ranney,  following  a  sug- 
gestion of  Foster's,"  offers  a  different  division,  which  is  rather  better. 
He  includes  in  the  pubic  segment  the  parts  above  mentioned  plus  the 
uterus  and  utero-sacral  ligaments.    The  pubic  segment  is  then  attached 

1  The  Structural  Anatomy  of  the  Femah-  Peine  Floor,  ISSl. 

^  Made  in  a  paper  on  ''  The  Mechanical  Action  of  Pessaries."  Am.  Gyn.  Trains.,  1881, 


234        THE  ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 

somewhat  loosely  to  the  symphysis,  more  firmly  to  the  sacrum.  Parallel 
with  the  former  is  the  sacral  segment,  which  is  "  firmly  dovetailed  into 
the  sacrum  and  coccyx."  Without  going  into  details,  it  will  at  once  be 
evident  that  the  sacral  segment,  as  a  whole  (including  the  perineal  body), 
acts  as  a  support  to  the  pubic,  and  thus  (acting  with  the  utero-sacral  lig- 
aments) maintains  the  uterus  in  its  normal  position. 

The  writer  can  subscribe  only  in  part  to  Foster's  positive  statement, 
that  "  except  to  resist  extreme  displacements  of  the  organ  the  broad 
ligaments,  the  round  ligaments,  the  bladder,  the  rectum,  and  the  peri- 
neum take  no  part  among  the  supports  of  the  uterus."  It  seems  better 
to  regard  the  uterus,  as  well  as  the  vagina,  as  upheld  by  the  "  compact, 
unbroken  pelvic  floor,"  the  perineum  being  "only  a  small,  though 
strong,  part  of  the  sacral  segment." 

Another  point  which  ought  not  to  be  overlooked  in  this  hasty  glance 
at  the  architectural  anatomy  of  the  pelvic  floor  has  reference  to  its  pro- 
jection beyond  the  conjugate  of  the  outlet.  This  has  been  studied  by 
several,  especially  by  Foster,  to  whose  paper  the  reader  is  referred  for 
details  on  this  subject,  as  well  as  for  careful  measurements  of  the  bony 
pelvis.^  His  average  estimate  of  this  projection  is  2.5  cm.,  the  patient 
being  semi-prone. 

Regarding  the  perineal  body  as  simply  a  portion  of  the  sacral  seg- 
ment of  the  pelvic  floor,  we  shall  be  disposed  to  attach  less  importance  to 
lacerations  of  the  body  which  do  not  involve  the  sphincter.  The  mechan- 
ism of  prolapsus  becomes  much  more  satisfactory  when  viewed  in  con- 
nection with  the  theory  that ''  the  chief  support  (of  the  uterus)  is  the  com- 
pact, unbroken  pelvic  floor,"  while  the  gynecologist  now  regards  the  use- 
ful rather  than  the  beautiful  in  the  performance  of  perineorrhaphy. 

Although  Dr.  Emmet  was  not  the  first  to  aflirm  the  insignificance 
of  the  perineal  body  as  a  support,  he  has  deduced  the  practical  lesson  that 
laceration  of  the  perineum  alone  impairs  but  little  the  integrity  of  the 
uterine  support,  whereas  overstretching,  or  tearing  of,  the  fascia  or  mus- 
cles (levatores  ani)  of  the  floor  at  their  attachment  to  the  vagina,  as 
the  result  of  parturition,  at  once  disturbs  the  delicate  adjustment  of  the 
pelvic  organs.  This  theory,  so  correct  logically,  has,  unfortunately,  not 
yet  received  confirmation  through  careful  dissections.  Assuming  that 
the  injury  in  such  cases  involves  the  deeper  tissues,  and  that  it  is  not 
repaired  by  closing  the  perineum  alone,  it  remains  to  inquire  if  the  new 
operation  proposed  by  Dr.  Emmet  does  fulfil  the  indications.  Granting 
that  the  tissues  of  the  pelvic  floor  are  lacerated,  does  the  operator  reunite 
the  torn  ends  by  passing  his  sutures  blindly  through  the  posterior  vagi- 
nal wall,  or  is  the  operation  simply  a  modified  posterior  colporrhaphy, 
the  ultimate  result  of  which  is  simply  to  narrow  the  vagina  by  the 
removal  of  redundant  tissue?^ 

1  Am.  Journ.  Obstetrics,  vol.  xiii.  p.  30.  ^  Comp.  Emmet,  op.  cit.,  ch.  xx. 


MALFORMATIONS  OF  THE  FEMALE 
GENITALS. 

Bv  iiKNiiv  J.  (;auki<;l:ks,  a.  m.,  m.  d., 

Ni;\v  YoKK. 


All  malformations  are  rof"eral)lo  to  one  of  two  lar^e  classes.  The 
first  of  these  com j)risos  those  eases  wliieh  are  due  to  an  c.rc<'.s-«  of  growth, 
wiiieh  a^iun  may  he  a  mere  liypci'jjlaski  or  uncommon  size  of  an  organ 
brought  on  by  an  increase  in  the  number  of  constituent  histological 
elements,  or  hi/perfj'ophi/,  by  which  is  designated  the  condition  in 
which  the  elements  themselves  are  enlarged ;  or,  on  the  other  hand, 
the  excess  may  be  characterized  by  a  multiplication  of  organs.  To  the 
other  much  more  numerous  and  important  class  belong  all  those  cases 
which  are  referable  to  an  arrest  of  development. 

Why  an  organ  should  increase  in  size  beyond  the  ordinary  limits,  or 
wiiy  it  should  appear  in  a  larger  number  than  usual,  is  not  clear.  We 
must  be  satisfied  with  stating  the  fact  that  sometimes  organs  do  obtain 
larger  dimensions  than  in  the  majority  of  cases.  Still  less  can  we 
understand  in  most  cases  how  a  multiplication  of  organs  is  brought 
about,  apart  from  those  cases  where  there  evidently  is  a  double  fa?tiLs, 
parts  of  which  have  not  been  developed,  while  the  two  foetuses  have 
grown  together.  We  do  not  know  by  what  process  sometimes  a  child 
has  six  fingers  instead  of  five,  four  breasts,  etc. 

In  the  second  cla.ss  our  intellect  finds  more  satisfaction.  W^liat 
formerly  was  a  chaotic  mass  of  different  freaks  of  Nature  has,  to  a 
great  extent,  become  a  system  of  well-connected  links  which  are  easily 
underst(jod  as  soon  as  we  study  them  in  the  light  of  embr^-ological 
development  as  described  in  the  preceding  article. 

The   Ovaries. 

Sometimes  the  ovaries  in  newborn  children  are  found  twice  as  large 
as  normal.  In  some  cases  it  is  a  simple  hyperplasia,  with  an  even 
increase  of  all  the  constituent  parts,  but  oftener  we  find  a  preponder- 
ance of  connective  tissue  and  a  more  or  less  complete  disappearance  of 
Graafian  follicles — a  condition  which  may  be  looked  upon  as  the  result 
of  a  fcetal  inflammation. 

235 


236  MALFORMATIONS  OF  THE  FEMALE  GENITALS. 

Supernumerary  ovaries  are,  according  to  Beigel,  not  rare.  He  found 
them  23  times  in  500  autopsies  of  adult  women.  They  were  only  small 
bodies,  of  the  size  of  a  pea  or  a  hazelnut,  but  showed  on  microscopical 
examination  the  complete  structure  of  the  ovarian  tissue,  especially 
follicles,  the  characteristic  element  of  an  ovary.  They  had  thin 
pedicles,  and  were  found  near  the  peritoneal  border  of  the  normal 
ovary,  and  once  on  the  surface  of  the  broad  ligament. 

Sometimes  the  ovaries  present  more  or  less  deep  fissures.  In  other 
cases  two  parts  have  been  found  bound  together  with  a  ligament,  and 
in  a  case  of  Grohe  there  was  a  large  ovary  on  one  side  and  two  small 
ones  on  the  other,  the  inner  one  of  which  was  bound  to  the  uterus  by 
an  ovarian  ligament,  the  outer  one  not  (Puech).  This  is  probably  only 
a  further  division  of  one  ovary. 

Olshausen  removed  a  large  multilocular  ovarian  cyst  which  was 
bound  by  a  pedicle  to  the  uterus,  and  yet  two  normal  ovaries  were 
found  in  tlieir  places  imbedded  in  a  mass  of  inflammatory  adhesions. 

Winckel  has  photographed  a  somewhat  similar  case  to  Grohe's,  and 
an  unique  case  in  Avhich  a  supernumerary  ovary  as  large  as  a  n6rmal 
ovary  was  bound  to  the  uterus  by  a  separate  ovarian  ligament.^ 

The  possibility  of  the  presence  of  a  supernumerary  ovary  must  be 
borne  in  mind  as  one  explanation  of  the  occurrence  of  pregnancy  after 
double  ovariotomy,  a  case  of  which  occurred  in  Norway  some  years  ago 
(Leopold  Meyer). 

Both  ovaries  may  be  absent — a  condition  commonly  only  found  in 
the  rare  cases  of  total  absence  of  the  uterus.  The  congenital  absence 
of  the  ovaries  entails  absence  of  menstruation,  but  the  female  type 
and  sexual  appetite  have  been  found  normal.  One  ovary  may  be 
totally  absent  in  an  individual  with  a  one-horned  uterus. 

That  the  ovaries  are  not  found  in  their  usual  place  is  not  a  sufficient 
proof  of  their  absence.  In  consequence  of  a  deficient  descent  they  may 
be  found  in  the  lumbar  region — a  condition  which,  however,  is  very 
rare,  and  has  only  been  found  in  connection  with  great  arrest  of  devel- 
opment in  other  respects. 

Sometimes  the  ovary  is  found  in  the  inguinal  canal,  or  even  in  the 
corresponding  labium  majus.  This  may  be  due  to  a  faulty  development. 
If  the  round  ligament,  instead  of  acquiring  its  normal  length,  stays 
short,  it  drags  the  tube  and  ovarv  and  sometimes  the  horn  of  a  bicor- 
nous  uterus  through  Nuck's  canal ;  that  is,  the  prolongation  from  the 
peritoneum  which  surrounds  the  round  ligament  during  its  passage 
down  throug-h  the  inguinal  canal  to  its  attachment  to  the  mons  Veneris 
and  the  large  labia. 

More  rarely,  the  ovary  alone,  without  the  tube,  is  found  in  such  a 
congenital  hernia.     That  it  can  come  down  during  intra-uterine  life  is 
1  Winckel's  Pathologie  der  Weiblichen  Semalorgane,  p.  28  and  table  xxxiv.  fig.  7. 


THE  FALLol'lAS    Tl'IiES.  2:57 

easily  iiiidcrsttuKl  wlicii  we  cxainiiic  the  relative  size  of"  tlie  ovar\'  and 
tlie  canal.  I'^'oni  the  titnrtli  t<i  tlii'  sixtli  ninntli  (»!"  f'retal  life  the  latter 
is  ()  niillinieters  wide  (rnrcii),  and  in  the  lilih  month  the  o\ar\-  is 
l.<!  inillimeti-rs  thick  and  'lA  inillinu'ter>  hi^h  (  Kc'iliiker).  It  is  of  so 
UHich  <::reater  ifn|>ortance  to  hear  in  mind  that  the  ovarv  can  he  found 
ill  these  imusiial  localities,  as  it  lias  here  hccoinc  the  seat  oi'  diseases, 
such  as  cystic  or  cancerons  de^■eneration,  re<jnirin;^-  snr<:ical  intei-t'creiice. 

Sometimes  one  oi-  Ix.th  ovaries  hecoine  severed  from  thej^enita!  aj»j)a- 
ratns  hy  foetal  inflammation,  and  may  either  l)e  found  adherent  to  some 
other  part  or  floatinii;  free  in  the  ahdominal  cavity. 

More  comm(»n  than  the  total  ahscnce  of  ovaries  is  a  rnfllmrnftirij 
clevclopiiicitf  of  these  or<::ans,  either  with  ])re-ei-vation  of  Graafian  fol- 
licles or  with  total  loss  of  these  latter,  in  which  ease  the  ovary  is  onlv 
formed  by  a  mass  of  connective  tissue.  As  a  rule,  the  rndimentarv 
development  of  the  ovaries  is  combined  with  a  similar  deficiency  in  the 
formation  of  the  litems;  but  sometimes  well-developed  ovaries  are 
fonnd  toiicther  witli  the  arrest  of  develo})ment  of  the  uterus;  and,  on 
the  other  han<l,  the  atro])liy  of  the  ovaries  may  i)e  found  in  women 
with  well-devcloj)ed  uterus  and  external  *ienitals.  Sexual  desire  mav 
be  ])resent,   but  such  women  do  not  menstruate. 

A'irchow  has  shown  that  the  ruiliuientarv  develo])ment  of  the  ovaries 
is  sometimes  combined  with  conuenital  faults  in  the  larue  blood-vessels, 
especially  stenosis  of  the  aorta  ;  and  ]Morel  has  pointed  out  the  frequent 
combination  of  a  rudinicutarv  development  of  the  ovaries  with  a  sim- 
ilar deficient  development  of  the  nerve-centres,  especially  in  cretins  and 
idiots. 

The  Fallopian  Tubes. 

The  oviducts  are  sometimes  unusually  large.  In  most  cases  this 
increase  is  the  consequence  of  the  presence  of  a  tumor  with  which 
the  tube  is  more  or  less  intimately  connected.  But  even  in  the  aljsence 
of  all  other  abnormities  the  tubes  have  been  found  16  or  17  centimeters 
(about  6J  inches)  long. 

Another  kind  of  excessive  formation  is  constituted  hy  .wpeniumcrary 
osiia  surrounded  by  fimbriae.  These  openings  may  be  found  on  one 
or  both  tubes.  They  are  ahvays  situated  at  the  upper  surface  and  near 
the  a1)dorainal  end.  How  they  are  produced  is  not  yet  known.  If 
Waldeyer's  views  about  the  formation  of  the  Fallopian  tube  as  an 
originally  open  canal  (see  p.  68)  were  true,  these  openings  might  be 
looked  upon  as  the  result  of  an  arrested  development ;  but  the  forma- 
tion of  the  fimbriae  which  surround  them  would  still  place  them  among 
malformations  by  excess. 

The  tubes  mav  be  ah.<tenf — a  condition  which  is  usually  coml)ined 
with  a  defect  of  the  uterus,  or  at  leiist  with  a  solid,  untunnelled  uterus. 


238  MALFORMATIONS   OF  THE  FEMALE  GENITALS. 

The  absence  of  one  oviduct  is  found  in  cases  of  a  one-horned  uterus. 
In  one  case  the  tube  on  one  side  was  absent,  although  the  uterus  was 
well  developed. 

All  these  varieties  are  easily  understood  when  we  remember  that  the 
tubes  are  only  the  upper  part  of  the  Miillerian  ducts,  a  malformation 
or  destruction  of  which  must  result  in  corresponding  deficiencies  in  the 
Fallopian  tubes. 

Sometimes  the  tubes  are  only  represented  by  feeble  streaks  of  con- 
nective or  muscular  tissue  at  the  upper  edge  of  the  broad  ligaments. 
At  other  times  the  tubes,  in  their  whole  course  or  in  some  part  of  it, 
are  represented  by  solid  strings.  This  condition  is  explainable  when 
we  remember  that  according  to  the  generally  accepted  doctrine  the 
Miillerian  tubes  begin  as  solid  filaments,  in  which  there  subsequently 
appears  a  bore. 

At  the  fimbriated  end  of  the  tube  is  often  found  a  pea-shaped  cyst 
called  Iforgagni's  hydatid.  Its  interior  is  lined  Avith  ciliated  epithe- 
lium like  that  of  the  tube,  and  it  contains  a  clear  fluid.  Formerly  this 
cyst  was  taken  to  be  the  upper  end  of  Miiller's  duct,  but,  as  we  have 
seen,  this  is  never  closed.  Besides,  this  cyst  is  only  found  in  one  out 
of  five  women  (De  Sinety).  It  is  therefore  now  looked  upon  as  a  jjatho- 
logical  formation.  Occasionally  it  becomes  enlarged  :  I  have  myself 
seen  it  the  size  of  an  English  walnut. 

The  Uterus. 

In  studying  the  malformations  of  the  uterus,  more  than  in  any  other 
part  of  this  disquisition,  it  is  of  the  greatest  importance  to  keep  in  mind 
the  teachings  of  the  history  of  foetal  development.  If  we  remember 
that  this  organ  is  formed  by  the  fusion  and  further  development  of  the 
middle  parts  of  the  Miillerian  ducts,  which  themselves  are  originally 
solid  filaments,  we  will  easily  understand  that  that  part  of  those  ducts 
which  should  form  the  womb  may  have  originally  been  absent  or  may 
have  been  destroyed,  or  that  the  filaments  continue  to  be  solid  columns 
without  bore,  or  that  the  muscular  tissue  which  in  the  course  of  time 
should  surround  these  tubes  fails  to  be  produced,  or  that  fusion  between 
the  tubes  does  not  take  place  at  all  or  does  so  only  imperfectly,  or  that 
one  tube  undergoes  its  regular  development  while  the  other  lags  behind 
or  is  altogether  absent.  On  the  other  hand,  an  excess  of  development 
may  take  place.  Thus  we  will  have  to  consider  the  following  con- 
ditions : 

A.  Excessive  development. 

B.  Arrest  of  development  during  the  first  half  of  intra-uterine  life  : 

I.  Absence  of  uterus. 
II.  Rudimentary  uterus. 


EXCEii^'ilVJ-:  DEVKUJl'MKyr  ASD   I'liEVUVITY.  2;i'J 

III.  Uterus  duplex  s('j)anitus. 

IV.  Uterus  uuicoruis. 
V.   Uterus  hiconiis. 

VI.  Uterus  septus. 
VI r.   Uterus  suhseptus. 
VII  I.    At  resin  uteri. 

C   Arri'st  of  (leveli>piueut  duriutr  the  seeoiid   half"  of"  iutra-uteriue 
lifl': 
I.  Uterus  fa?talis  aud  uterus  iufairtilis. 
II.  Uterus  puheset'us. 

III.  Uti'rus  iueudiforuiis. 

IV.  Uterus  j)arvieollis  or  aef)llis. 
V.  Auteflexion. 

D.  Irre«2:ular  development : 
I.  Obliquity. 
II.  Later()})(>siti()U, 

III.  Anteposition. 

IV.  Postposition, 
\.  Hernia  uteri. 

VI.  Abnormal  eommunications. 


A.   Excessive  Development  and  Precocity. 

Sometimes  the  uterus  of  newborn  children  has  been  found  to  equal 
that  of  a  "irl  near  puberty,  not  only  in  size  and  mass,  but  in  the  pro- 
portions between  the  neck  and  the  body.  (See  p.  90.)  In  many  eases 
menstruation  has  begun  in  early  childhood.  Kerkring  saw  it  appear  at 
the  birth  of  the  child  and  continue  regularly.  Langlade  and  Cummen 
observed  it  between  the  eighth  and  the  twentieth  day  of  the  child's  life 
(Klob).  Bouchut  has  published  the  history  of  a  child  four  years  old 
who  had  well-developed  breasts,  pubes,  and  external  genitals,  and  Avho 
had  menstruated  regularly  since  it  was  twenty-two  months  old.' 

Proehownick  has  proved  by  post-mortem  and  microscopical  examina- 
tion that  such  a  case  of  precocious  menstruation  was  combined  with,  not 
to  say  depended  on,  a  precocious  development  of  the  uterus  and  the 
ovaries.  The  child  was  scrofulous  and  rickety,  three  years  old,  and  had 
menstruated  regularly,  for  the  last  two  years,  three  days  in  every  four 
weeks.  The  child  died  immediately  after  a  menstruation.  The  breasts 
were  only  a  little  developed,  but  on  either  side  a  small  movable  lump 
of  glandular  tissue  was  found.  The  hair-growth  was  somewhat  more 
abundant  than  normal.  The  vagina  measured  o  centimeters,  the  uterus 
4  cm.,  two  of  which  belonged  to  the  body  ;  that  is,  twice  the  normal 
depth.  The  inside  had  a  greenish  color  and  was  covered  with  a  thin 
»  Paris  Medical,  Dec  22,  1876. 


240 


MALFORMATIONS  OF  THE  FEMALE  GESITALS. 


greenish-yellow  mucus,  although  the  parts  were  entirely  fresh.  JNIicro- 
scopical  examination  showed  that  the  superficial  layer  and  the  mucous 
were  composed  of  glandular  tubules,  epithelial  lining,  and  detritus  mixed 
with  numerous  red  blood-corpuscles,  innumerable  leucocytes,  and  a  few 
pus-corpuscles.  The  right  ovary  measured  2  cm.  in  length,  1,3  cm.  in 
height,  and  0.3  in  thickness;  the  left  was  3.5  long,  1.5  high,  and  0.25 
thick.  These  long  and  high  but  thin  ovaries  showed  notches  and 
puckerings,  as  those  of  a  senile  woman.  In  the  left  was  found  a  freshly- 
ruptured  follicle  in  the  first  stage  of  transition  into  a  corpus  luteum. 
Microscopical  examination  showed  nearest  the  surface  a  zone  of  young 
follicles,  and  in  the  deeper  layers  much  larger  follicles,  while  the 
stroma  was  remarkable  for  its  richness  in  blood-vessels  compared 
with  that  of  another  child  of  the  same  age. 


B.    Arrest   of   Development   during   the   First   Half   of 
Intra-uterine  Life. 
I.  Absence  of  the  UxEErs. — It  has  often  been  claimed  that  the 
uterus  was  absent  in  cases  in  which  such  an  assertion  was  not  warranted 


Fig 


^^ 


a,  ribbon-shaped  rudiment  of  the  uterus  :  6,  6,  the  round  ligaments ;  c,  e,  Fallopian  tubes;  d,  d, 
ovaries.    (From  Kussmaul,  after  Nega.) 

by  the  examination.  All  observations  which  regard  living  persons  must 
be  eliminated,  as  the  womb  may  be  so  rudimentary  as  to  escape  detec- 
tion even  bv  the  most  skilful  examiner.    The  total  absence  of  the  womb 


ARREST  OF  DEVELOPMENT. 


241 


(•;m  oiilv  lie  |»ru\c(l  1)\-  :i  caicriil  |i(ist-iii(ii'lfiii  cxaiiiiiiatioii  ;  ainl  even 
then  tlu'  (iWscrvtT  is  lial)l('  t<»  Ix'  led  astray.  IK-  iimsl  cspcc-iallv  tliiiik 
of  the  |u)ssil)ilify  that  the  supposed  woman  be  really  a  man  with  female 
external  <;enitals  and  hidden  testicles.  He  must  furthermore  distin- 
ii-iiisii  a  nidiiiu'iitarv  uterus  from  a  Fallopian  tuhe,  the  limit  hctween 
the  two  being  the  point  of  insertion  of  the  round  ligament.     The  eom- 


Fio.  81. 


A,  External  View  :  a,  a,  the  labia  majora,  tbat  lay  in  close  contact,  but  here  are  drawn  apart: 
6,  b.  the  labia  minora  ;  c,  the  opening  of  the  urogenital  sinus ;  d,  anus,  with  normal  rectum : 
€,  flap  of  skin ;  /.  the  external  opening  of  the  left  iliac  canal,  from  which  protrudes  the 
round  ligament,  which  spreads  in  the  adipose  tissue.  B,  Sagittal  Section :  a,  urogenital 
canal,  which  here  almost  exclusively  represents  the  urethra;  6,  bladder;  c,  small  blind 
pouch  at  the  upper  end  of  the  urogenital  canal;  d,  fine  ridge  detaching  itself  on  both -sides 
from  the  wall  of  the  urogenital  canal,  and  forming  a  rudimentary  partition  of  the  same 
into  an  urethra  and  a  vagina;  e,  peritoneal  covering  of  bladder;  /,  section  of  the  flat  uterus, 
over  which  the  peritoneum  is  extended  without  forming  any  deep  pouch  between  it  and 
the  bladder :  it  is  bound  to  the  bladder  by  means  of  loose  connective  tissue :  (i,  symphysis 
pubis;  h,  labia  minora;  (,  labia  majora.  C,  View  from  the  Peritoneal  Cavity,  behind  the 
Uterus:  a,  bladder,  incised;  b,  b,  ureters;  c,  c,  umbilical  arteries;  d,  rectum;  e.  very  flat 
uterus,  the  lower  part  of  which  has  not  been  developed ;  /,/.  the  round  ligaments,  or  rather 
horns,  of  the  uterus;  p.  internal  opening  of  the  inguinal  canal,  through  which  the  round 
ligaments  go  to  the  adipose  tissue  of  the  labia  minora;  /),  h,  very  small  and  flat  ovaries;  k, 
peritoneal  fold  in  which  the  ovaries  are  imbedded.    (From  Kussmaul,  after  Langenbeck.) 

plete  absence  of  even  a  rudimentary  uterus  is  rare.  In  our  own  litera- 
ture we  have  two  cases  examined  post-mortem  by  Dr.  I.  E.  Taylor,  and 
there  are  a  few  other  authentic  cases  on  record. 

The  absence  of  the  uterus  may  be  found  alone,  but  is  more  commonly 

Vol.  I.— 16 


242 


MALFORMATIONS   OF  THE  FEMALE  GENITALS. 


combined  with  other  developmental  faults  of  the  genitals  or  other  parts 
of  the  body.  Thus  in  J.  T,  Whittaker's  case,  in  which  utero-gestation 
had  progressed  six  months,  the  external  genitals  were  only  represented 
by  a  rudimentary  clitoris ;  the  urethra  and  the  anus  were  absent,  the 
ovaries  atrophic,  and  the  tubes  devoid  of  fringes.  In  a  recent  case, 
reported  by  Coen  of  Bologna,  of  a  girl  born  at  eight  months'  gesta- 
tion, the  absence  of  uterus  and  vagina  was  combined  with  absence  of 
the  kidneys  and  deficient  development  of  the  eyeballs,  while  the  exter- 
nal genitals,  the  tubes,  and  ovaries  were  normal. 

II.  Rudimentary  Uteeus.— The  subject  of  the  malformations  of 
the  uterus  has  become  considerably  complicated  by  the  fact  that  dif- 
ferent authors  use  the  same  term  for  different  things  or  designate  the 
same  conditions  by  different  expressions.  In  the  following  pages  we 
will  use  KussmauFs  names,  his  work  being  by  far  the  most  important, 

Fig.  82. 


a 

uterus  Bipartitus  of  a  servant-girl  sixty  years  of  age :  a,  vagina,  about  one  inch  deep,  and  end- 
ing at  the  anterior  wall  of  the  rectum,  above  the  internal  sphincter;  6,  connective  tissue 
interspersed  with  muscular  fibres,  simulating  the  shape  of  a  uterus ;  c,  c,  fleshy  strings  rep- 
resenting the  horns  of  the  uterus ;  d,  d,  swellings  of  the  size  of  a  bean,  one  cut  open  and 
showing  a  cavity  of  the  size  of  a  lentil  and  lined  with  mucous  membrane ;  e,  e,  rudiment- 
ary ovaries ;  /,  /,  Fallopian  tubes ;  g,  round  ligaments ;  h,  broad  ligaments.  (From  Kuss- 
maul,  after  Mayer.) 


but  at  the  same  time  add  those  used  by  others,  and  indicate  when 
Kussmaul's  terms  are  used  by  others  in  a  different  sense. 

1.  In  some  cases  in  the  place  of  the  uterus  there  has  only  been  found 
a  globular,  solid,  fibrous  mass  of  the  size  of  a  hazelnut. 

2.  In  Nega's  case  (Fig.  80)  the  uterus  was  reduced  to  a  narrow  flat 
muscular  band,  without  any  cavity,  forming  a  transverse  arch  in  the 
pelvis. 

3.  In  a  case  described  by  Langenbeck  (Fig.  81)  the  uterus  is  like- 
wise formed  by  a  solid  flat,  muscular  mass,  as  in  Nega's,  but  the  mass 


AliRKST  OF   l)i:vi:i.nrMi:ST.  lAW 

lias  tlic  >lia|)t'  III  the  1)im|\  nl'  the  iKcni-,  and  lioiii  it>  cfiriicrs  starts  uii 
eitluT  side  a  nuiml  striiii;-  wliidi  ciitci-s  llic  injriiiiial  canal,  and  wliidi 
(•(msc(jiiciitly  ri'|»i'cs('nts  partly  the  li<>i-ii  dl"  tli<'  iitcni>  and  |)artl\-  the 
round   ligament.      Tlu'rc  is   no  neck. 

4.  A  transition  Ix'twcvn  the  solid  and  iinjluw  I'orins  oi'  rudiniciitarv 
\vond)s  is  f"oriuo<l  by  what  was  first  described  by  l*rof.  Mayer  of  Bonn 
under  tlu'  name  nt'  uterus  hipdrtitus^  (1''^-  ^^)'  This  kind  of  rudiment- 
ary uterus  is  not  so  extremely  rare  as  those  hitherto  consideretl,  which 
arc  only  represented  by  one  or  two  cases.  It  is  characterized  by  the 
presence,  between  tlie  bladder  and  the  rectum,  of"  a  body  which  has 
somewhat  the  shape  of  a  uterus,  and  which  is  composed  of  connective 
tissue  with  interspersed  muscular  fibres.  At  the  uj)per  end  it  sends  off 
to  both  sides  a  cord  of  similar  composition,  which,  at  the  point  of 
insertiim  of  the  round  ligament,  forms  a  small  muscular  swelling, 
which  either  is  solid  or  contains  a  small  cavity  lined  with  a  mucous 
membrane.  These  cords  represent  the  horns  of  the  uterus.  With  its 
lower  end  the  fibro-muscular  body  rests  on  the  cul-de-sac  of  a  short 
vagina  or  on  the  solid  fibrous  column  which  replaces  that  organ. 

The  late  E.  R.  Peaslee  has  described  a  solid  uterus  in  the  first 
volume  of  the  Transactions  of  the  American  Gynecological  Society 
(Fig.  83).-  It  was  taken  from  the  body  of  a  woman  twenty-four 
vears  old.  "  A  hard  conical  nodule  was  found  on  introducino;  the 
hand  through  the  abdominal  incision  on  each  side,  the  two  meet- 
ing behind  the  bladder  at  their  apices  in  a  pretty  firm  mass  of 
tissue.  The  finger  introduced  into  the  vagina  was  arrested  at  about 
three  inches,  and  above  this  point  to  the  union  of  the  nodules  above, 
a  distance  of  about  one  and  a  half  inches,  nothing  existed  in  the  wav 
of  fibrous  cords,  nor  the  slightest  canal  except  some  blood-vessels. 
From  the  outer  and  anterior  portion  of  the  nodules  the  round  liga- 
ments were  seen  to  be  given  off  and  to  take  their  normal  course  to 
the  internal  abdominal  ring."  The  nodules  showed  no  cavitv.  The 
figure  which  accompanies  the  description  shows  that  the  tissue  which 
formed  the  connection  between  the  two  nodules  had  the  form  of  the 
intermediate  part  of  a  uterus,  and  it  is  stated  that  that  likewise  was 
solid. 

The  uterus  hiparfitus  may  have  a  neck.     Then  there  are  three  more 

^  Lefort  applies  the  name  uterm  bipnrdtus  to  any  kind  of  double  uterus,  lUeriis  didiic- 
tiis  (i.e.  flidclph'/.f),  ntent.^  bicorni.'^,  and  ulerus  globulari.-i  \\.e.septii.<).  Uterus  bipartitus 
(Mayer.  Knssmaul)  is  by  others  designated  as  u(erii.<  bijidns.  On  the  other  hand,  the 
term  bijid  is  by  Playfair  (Science  and  Practice  of  Midwifenj,  London,  1876,  vol.  i.  p.  43) 
used  as  a  synonym  of  doMe,  and  applied  to  a  uterus  bicornis  unic/)!li.i. 

The  term  double  uterus  is  used  in  very  different  senses,  and  does  not  designate  any 
particular  kind  of  malformation.  It  ought  only  to  be  used  as  a  general  term,  compris- 
ing the  uterus  didelphys,  the  uterus  bicornis  duplex,  and  the  uterus  septus. 

*  Am.  Gyn.  Trans.,  1876,  i.  347. 


244 


MALFORMATIONS   OF  THE  FEMALE  GENITALS. 


developed  muscular,  perhaps  hollow,  parts  united  by  more  membranous 
or  cord-like  parts. 

5.  On  the  other  hand,  there  may  be  two  well-developed  horns  sep- 
arated by  an  incomplete  septum,  without  neck  {uterus  bicornis  acollis). 

6.  Vesicular  Uterus. — The  rudimentary  uterus  may  only  consist  of  a 
membranous  vesicle  with  or  without  neck.     In  none  of  the  cases  of 


A,  the  two  unequal  solid  masses  representing  the  cornua  and  part  of  the  corpus  of  the  bipartite 
uterus;  E,  the  remainder  of  the  organ,  also  solid,  the  fundus  of  the  empty  bladder  lying  on 
a  level  with  its  lower  border ;  C,  C,  the  commencement  of  the  two  round  ligaments ;  B,  the 
right  Fallopian  tube,  the  left  being  crossed  by  the  line  ascending  from  the  left  round  liga- 
ment; D,  stump  whence  the  left  ovary  had  been  removed,  that  of  the  right  side  being 
behind  the  convolutions  of  the  Fallopian  tube;  F,  pavilion  of  the  left  tube,  below  the  lat- 
ter: the  right  pavilion  is  seen  to  be  higher  than  the  left,  the  left  ovary  having  been  one 
inch  lower  in  the  pelvis  and  farther  back  than  usual;  O,  right  ovary  laid  open,  showing 
gray  spots  of  colloid  degeneration,  ovisacs,  and  colloid  cysts ;  H,  left  ovarj%  showing  cysts 
filled  with  colloid,  and  the  polypoid  mass  on  its  lower  extremity— namely,  a  colloid  cyst 
into  which  hemorrhage  had  occurred.    (From  Peaslee.) 


rudimentary  uterus,  the  authenticity  of  which  has  been  proved  by 
autopsy,  did  the  women  menstruate,  but  they  suffered  often  from 
monthly  molimina,  and  in  some  few  cases,  in  which  it  was  impos- 
sible on  the  living  to  find  any  uterus,  there  was  a  periodic  discharge 
of  blood  from  the  genitals. 

III.  Uterus  duplex  sepaeatus,  s.  didelphys  (o;c,  twice ;  oeX(phi^, 
womb ;  Uterus  diductus,  Lefort). — This  is  the  type  produced  when  the 
Miillerian  tubes  do  not  even  come  in  contact  with  one  another  in  that 
part  of  their  course  in  which  they  ought  to  melt  together  and  form  the 


AIiJ:KST  OF  UEVKLorMKyT. 


24; 


iitcnis.  C()iisc<|ii('iitly,  we  have  two  entirely  separate  iit<'ri,  hut  eaeli 
ot"  tlieiii  repit'seiits  uulv  oiie-lialt"  ol"  tlie  orj^au.  Alxtve,  it  joins  a  J''al- 
I(»i)iaii  tiilx' ;  l)t'l<i\v,  eacli  cervix  may  npeii  into  a  separate  vagina,  or 
the  hitter  or^an  may  he  more  or  k'ss  (h-feetive.  The  uteniH  dnjjlr.r 
neiHirnhts  has  mostly  i)een  fitnnd  in  stillhorn  ehildren  or  sueh  as  <lie<l 
SfK^n  alter  l»irth,  Imt  ( )lli\ier's  s|)ecim('n,  w  liich  we  reproduce  here  (Fig. 
<S4),  came  iVoni  a  woman  wiio  was  torty-two  years  old  and  had  heen 
pregnant  five  times.  Dirner's  patient  was  twenty-seven  years  (jld  and 
had  had  (»ne  miscarriage. 

In  t\iQ  Ainirlcdii  Joiinidl  of  Ohsfetrirs  (187(5,  vol.  ix.  ]>.  Ool)  is  i'ound 
a  report  ot"  a  ea.se  relateil  to  the  Xew  York  Ohstetrieal  Society  by  the 

Fig.  84. 


Uterus  Didelphys :  a.  right  cavity ;  b,  left  ca^^ty ;  c,  right  ovary :  d,  right  round  ligament :  e, 
left  round  ligament ;  /,  left  tube ;  </.  left  vaginal  portion ;  /(.  right  vaginal  portion  :  /.  right 
vagina ;  j,  left  vagina :  /:.  partition  between  the  two  vaginte.   ( From  De  .Sinety,  after  OUivier.) 


late  Dr.  E.  R.  Peaslee,  under  the  heading  "  Uterus  didelphys  septus 
and  Vagina  septa  ;"  but  since  it  is  stated  that  "  the  septum  ran  through 
up  to  the  fundus  uteri,"  and  that  "  the  uterus  was  not  bieornis,"  it  is 
evident  that  this  was  not  a  uterus  didelphys,  but  a  uterus  septus  duplex, 
which  will  be  described  below. 

Xear  the  uterus  didelphys  stands  the  uterus  described  by  Cooper 
Rose  :^  On  either  side  of  the  pelvis,  resting  on  the  rami  of  the  isehia, 
were  two  bodies  three-quarters  of  an  inch  in  length,  broad  below  and 
tapering  above,  separated  from  one  another  by  a  space  of  more  than  an 
inch,  not  connecting  with  one  another  or  externally.  The  body  on  the 
left  side,  being  cut  open,  was  found  to  be  one  lateral  portion  of  the 
uterus,  having  a  central  cavity  lined  with  rnucous  membrane,  and  com- 

1  Lond.  Obst.  Tram.,  1874,  vol.  xv.  p.  128. 


246 


MALFORMATIONS  OF  THE  FEMALE  GENITALS. 


mimicating  at  its  upper  end  with  a  pervious  Fallopian  tube  having 
attached  to  it  a  small  ovary  and  terminating  in  a  fimbriated  extremity. 
There  was  no  cervix  or  vagina  to  this  portion.  On  the  body  on  the 
right  side  existed  a  cervix  and  vagina,  the  latter  without  any  external 
opening.  This  side  had  a  Fallopian  tube  and  ovary  like  the  other. 
In  this  case,  then,  the  Mlillerian  ducts  have  remained  separate ;  the 
right  remained  imperforate  at  its  lower  end  ;  of  the  left,  the  lower  part, 
which  should  have  formed  the  cervix  and  vagina,  had  not  been  formed 
or  had  been  destroyed. 

IV.  Uterus  unicornis. — The  one-horned  uterus  (Fig.  85)  is  formed 
by  the  development  of  one  of  the  Miillerian  tubes,  while  the  other  is 
absent  or  rudimentary.     The  one-horned  uterus  is  always  very  long  in 

Fig.  85. 


Uterus  Unicornis :  iiT,  left  horn ;  ir,  left  tube;  io,  left  ovary;  £Lr,  left  round  ligament;  RH, 
right  horn  ;  RT,  right  tuhe ;   Ro,  right  ovary  ;  RLr,  right  round  ligament.    (From  Schroeder.) 

proportion  to  its  width,  forms  a  curve  with  the  concavity  turned  out- 
ward, and  ends  in  a  point  from  which  start  a  Fallopian  tube,  an  ovarian 
ligament,  and  a  round  ligament.     It  has  no  fundus. 

Pregnancy  in  a  strictly  one-horned  uterus  does  not  vary  materially 
from  that  in  a  normal  one.  If  there  be  a  rudimentary  horn,  both 
horns  develop  a  decidua,  and  a  foetus  may  be  formed  in  both  or  in  either 
of  them.  If  the  development  takes  place  in  the  rudimentary  horn, 
there  is  great  danger  that  it  will  not  be  able  to  develop  muscular  sub- 
stance enough  for  sheltering  the  icetus  through  the  whole  normal  period 
of  utero-gestation.  As  a  rule,  the  rudimentary  horn  is  ruptured  by 
the  increasing  bulk  of  the  foetus.  Such  cases  may  be  taken  for  a  rup- 
ture of  the  Fallopian  tube  if  the  observer  does  not  bear  in  mind  that 
the  round  ligament  offers  a  safe  landmark.  If  the  foetal  sac  is  situated 
inside  of  the  ligament,  it  belongs  to  the  uterus ;  if  developed  outside 
of  it,  it  is  tubal.  In  very  rare  cases  menstrual  blood  has  been  found 
to  collect  in  the  rudimentary  horn,  so  as  to  form  a  unilateral  hemato- 
metra. 

V.  Uterus  bicornis. — When  the  Mtillerian  ducts  stay  more  or 


AIUU'ST  or  DF.VELOI'MF.Sr. 


247 


less  soparatcd  fVoin  otic  aiiotlicr  in  that  |)arl  <»1"  tlicir  course  whieli 
<'orr('S|)oii(ls  to  tilt'  ii|t|>(i'  part  ot"  the  uterus,  this  oriiaii  is  at  its  upper 
rntl  tlividcd  iiittt  two  horus.  As  to  the  lower  pai"t  ol"  the  uterus,  it 
may  varv  in  (levclopincnt.  In  some  easi-s  there  are  two  eavitie^s 
entirely  separat<'(l  <r<tm  one  another  hy  a  partition  an<l  havinj^  each 
a  eervix  {uterus  fiicornis  <liij)lex,  Fi<>:s.  80  and  87).  In  other  easc^  the 
separation    is   oiilv    I'ouiid    in    the   hody   of  the   ut<'riis,  while    heh»w   the 

Fr;.  ««. 


Uterus  Bicornis  Duplex,  from  a  virgin  thirty  yours  old:  «,  left  horn;  6,  cavity  of  right  horn; 
c,  right  cervical  canal;  d,  d,  external  orifices;  e,  e,  the  two  vaginal  canals;  /,  partition 
between  the  vaginal  canals;  (/,.';,  tubes ;  A, /i,  ovaries;  «,  i,  cysts  of  the  ovaries  ;  t,  it,  round 
ligaments;  /,  suspensory  ligament  of  uterus  or  recto-vesical  ligament.  (.From  Kussmaul, 
after  Cassan.) 


Miillerian  tubes  have  been  fused  together  in  the  normal  way,  so  as  to 
form  a  single  cervix  {utei'us  bicornis  unicoUis,  s.  infra  simplex,  s.  semi- 
duple.v,  Fig.  88). 

A  still  smaller  degree  of  separation  is  found  in  the  form  of  uterus 
which  Kussmaul  calls  uterus  arcuatus  [uterus  corrJifoi-mis,  uterus  echan- 
cre  cordiforme,  Barth).  On  the  outer  surface  (Fig.  89)  there  is  only 
a  shallow  notch  between  the  two  horns,  as  in  some  forms  of  uterus 
bicornis  duplex,  and  inside  the  se])tuni  is  reduced  to  a  ridge  running 
over  the  fundus  in  an  antero-posterior  direction.     It  looks  as  if  the 


248 


3IALF0R3IATI0NS   OF  THE  FEMALE  GENITALS. 


fundus  had  been  bent  inward  toward  the  cavity  in  the  median  line,  by 
which  disposition  both  the  whole  uterus  and  its  cavity  acquire  a  shape 
somewhat  Hke  the  heart  on  playing-cards. 


Fig.  87. 


a 

Uterus  Bicomis  Duplex:  a,  double  entrance  to  vagina;  6,  meatus  urinarius;  c,  clitoris;  d, 
urethra;  e,e,  double  vagina;  /,/,  external  orifices  of  uterus;  g,g,  double  cervix;  h.  h, 
bodies  and  horns  of  uterus;  i,  i,  ovaries;  7;,  k,  tubes;  I,  I,  round  ligaments;  m,'m,  broad 
ligaments.   (From  Kussmaul,  after  Eisenmann.) 

VI.  Uterus  septus  ( Uterus  cloisonne,  Cruveilhier ;  Uterus  bilocv^ 
laris,  Eokitansky ;  U.  glohularis,  Lefort). — Much  rarer  than  the  bicor- 
nuted  uteri  are  those  which  in  consequence  of  the  normal  development 
of  the  fundus  outwardly  present  the  appearance  of  a  single  uterus^  but 
in  which  the  cavity  is  divided  by  a  more  or  less  complete  longitudinal 
septum  into  two  halves. 

If  the  partition  is  complete,  this  kind  is  called  uterus  septus,  or  by 
redundancy  utei%is  septus  duplex  (Fig.  90) ;  if  it  is  incomplete,  we  have 
a  uterus  suhseptus. 


ARREST  OF  DEVELOPMENT. 


249 


Fici.  88, 


Uterus  Bicornis  UnicoUis  of  a  virgin :  a,  vagina ;  6,  single  neck ;  c,  c  horns ;  d,  d,  tubes ;  e,  e, 
ovaries;  /,/,  round  ligaments.  (From  Kussmaul.) 

YII.  Uterus  subseptus  ( TJ.  semipartitus,  Lefort)  is  a  uterus  which 
looks  outside  like  a  single  uterus,  but  is  divided  interually  by  an  iucom- 


Utcrua  Arcuatus  :  a,  indented  fundus ;  b,  6,  tubes ;  c,  c,  round  ligaments :  d,  central  longitudinal 
ridge  on  the  posterior  wall  of  the  cavity  of  the  body :  e,  e,  lateral  ridges  of  the  same ;  /, 
internal  os;  g,g,  neck  of  the  womb.  (From  Kussmaul.) 

plete  longitudinal  partition  (Fig.  91).     If  the  partition  extends  do^vn 
through  the  body  and  part  of  the  cervix,  so  as  to  leave  only  one  open- 


250 


MALFORMATIONS  OF  THE  FEMALE  GENITALS. 


ing  at  the  os  externum,  the  variety  is  called  uterus  subseptus  uriiforis. 
If  it  stops  at  the  os  internum,  we  have  the  variety  called  uterus  sub- 
septus unicollis.  If  it  extends  only  partially  down  from  the  fundus 
through  the  body,  that  variety  is  called  uterus  subseptus  unicorporem. 
On  the  other  hand,  the  septum  may  only  be  found  near  the  os  exter- 
num, thus  forming  a  uterus  biforis  supra  simjjlex. 

A  peculiar  variety  standing  very  near  the  last  one  is  that  observed 
by  "  a  Western  physician,"  and  reported  to  the  New  York  Obstetrical 

Fig.  90. 


Uterus  Septus  Duplex  (natural  size),  completely  double  uterus  and  incompletely  double  vagina 
of  a  girl  twenty -two  years  old  :  a,  a,  tubes ;  6,  b,  fundus  of  the  double  uterus ;  c,  c,  c,  parti- 
tion of  uterus;  d,  d,  cavities  of  the  uterine  bodies;  e,  e,  internal  orifices;  /,/,  external  walls 
of  the  two  necks ;  g,  g.  external  orifices  ;  h,  h,  vaginal  canals ;  i,  partition  which  divided  the 
upper  third  of  the  vagina  into  two  halves.    (From  Kussmaul.) 

Society  by  Dr.  P.  F.  Munde.  The  patient  was  a  woman  of  middle 
age  who  had  been  married  ten  years.  She  was  treated  for  leucorrhoea, 
and  a  discrepancy  between  her  statement  about  the  continuance  of  the 
discharge  and  the  doctor's  own  observation  that  the  cervix  got  well 
under  appropriate  treatment,  led  to  the  discovery  of  a  second  and  nar- 
rower vagina  leading  to  another  cervix.  By  meaps  of  two  sounds  the 
doctor  convinced  himself  that  the  septum  in  the  vagina  was  complete, 
and  that  it  extended  somewhat  into  the  cervix,  while  there  was  no  trace 


Ai:ni:s'r  of  devkiju'MEST. 


251 


Vu,.  ',11 


Uterus  Septus  Uniforis:  a,  vagina:  h,  single  os  uteri;  e,  partition  of  uterus,  tliick  above,  tiiin 
below ;  d,  d,  right  and  left  uterine  cavities ;  e,  e,  two  ridges  on  the  posterior  wall  of  the  cer- 
vix. (From  Kussmaul,  after  Gravel.) 

of  a  septum  in  the  body  of  the  uterus  (Figs.  92  and  93).     This  form 
differs  from  the  uteriLS  subseptus  biforis  by  the  presence  of  t^vo  vaginal 

Fig.  93. 


Fig.  92. 


'-—A 


Fig.  92. — a,  left  vaginal  entrance ;  6,  right  vaginal  entrance. 

Fig.  93.— Ideal  Section,  showing  double  vagina  and  neck,  single  body  :  -■1,  left  vagina ;  B,  right 
vagina;  C,  partition  dividing  the  neck  of  the  womb. 

portions.    As  the  woman  had  borne  a  child  by  a  premature  birth  at  the 
sixtli  month,  there  may  possibly  have  been  a  complete  septum  which 


252  MALFORMATIONS   OF  THE  FEMALE  GENITALS. 

was  destroyed  during  labor.  In  M.  Duncan's  case  of  uterus  subseptus 
the  cervix  was  single,  and  the  "  firm  septum  of  the  uterine  cavity  ended 
at  its  upper  part  in  a  smooth,  broad-edged  end."  Thus  there  must  have 
been  a  free  space  between  the  septum  and  the  fundus  ;  and  since  its  end 
was  smooth  and  broad,  that  means,  probably,  that  it  had  not  been  torn 
during  the  preceding  delivery. 

In  all  forms  of  double  uterus,  be  it  horned  or  not,  the  vagina  mav 
be  single  or  double.  If  there  is  a  double  vagina,  there  commonly  is  a 
vaginal  portion  in  each  half.  Exceptionally,  there  is  only  one  prom- 
inence, divided  internally  by  a  septum.  Sometimes  there  is  one  cervi- 
cal portion  opening  with  two  openings  into  one-half  of  the  vagina,  the 
other  half  ending  blind  superiorly ;  which  cannot  be  explained  as  a 
simjjle  arrest  of  development,  but  constitutes  an  irregularity.  In  a  case 
described  by  Cruveilhier  there  was  a  single  vagina  with  a  single  vaginal 
portion. 

In  women  with  double  uterus  the  menstrual  flow  comes  sometimes  from 
both  halves  of  the  uterus,  sometimes  from  one  only ;  and  if  it  comes  from 
both,  it  may  come  at  different  times  from  the  two  halves  (Kussmaul). 
In  the  case  of  the  ''  Western  physician "  mentioned  above  a  specular 
examination  performed  during  menstruation  showed  that  the  discharge 
came  from  both  orifices  of  the  uterus  at  the  same  time.  Dr.  T.  A. 
Emmet ^  has  reported  a  case  of  double  uterus  and  double  vagina,  with 
imperforate  hymen  on  one  side,  in  which  there  never  was  a  show  at  less 
than  two  months'  interval.  The  doctor,  therefore,  thought  it  likely  that 
the  patient  menstruated  from  the  two  uteri  alternately.  Dr.  H.  F.  Walker 
has  described  ^  the  case  of  a  woman  with  uterus  septus,  double  vagina,  and 
double  vaginal  portion.  In  this  case  menstruation  recurred  eveiy  two 
weeks.  It  is  therefore  possible,  although  not  proven,  that  both  halves 
had  a  monthly  period,  but  at  different  times.  Dr.  John  Aikman's  case  is 
conclusive,  since  it  afforded  the  opportunity  of  a  post-mortem  examina- 
tion. The  patient  died  at  the  end  of  menstruation.  She  had  a  double 
uterus  and  vagina.  The  mucous  membrane  of  the  left  cavity  was  cov- 
ered with  a  grayish  shreddy  structure  and  opaque  mucus,  but  the  mem- 
brane itself  was  firmly  adherent  and  in  no  part  absent.  That  of  the 
right  was  quite  unaltered.  In  the  left  ovary  was  found  a  dark-colored 
granular  clot,  which  had  evidently  been  a  Graafian  "  vesicle ;"  that  is 
to  say,  it  was  a  ruptured  Graafian  follicle  filled  with  a  blood-clot.  In 
this  case,  then,  evidently  only  one  half  of  the  uterus  was  implicated  in 
the  menstrual  process. 

Pregnancy  occurs  in  a  double  uterus  as  easily  as  in  a  single.  One 
or  both  halves  may  become  the  seat  of  development  of  a  foetus.  Even 
if  the  pregnancy  is  limited  to  one  side,  as  a  rule  the  other  side  partici- 
pates more  or  less  in  the  development  during  gestation,  increasing  in 

^  Trans.  Am.  Gyn.  <Sbc.,  vol.  ii.  p.  444.  '^  Am.  Journ.  Obstetrics,  vol.  viii.  p.  515. 


ARREST  OF  Dh'Vh'l.OlWfhWT.  253 

si/f,  protliiciiiij,'  new  iiiiisciilai'  tissue,  ;iii<l  roniiiii^-  a  dccidiia.  In  mhhc 
cases  tlie  <is  opens  t»ii  Itntli  sides  diii'inu  lalmi',  in  <>tliei"s  not.      The  fol- 

Idwiiiij;  case  came  under  my  lu'i'sona!   (»l)>ervati<fn  :  ( '.  Y ,  iut.  20, 

])riini|)ara.  Tlic  Hrst  mcnstruatinn  (lecnrrcd  when  she  was  thirteen 
veai's  old.  She  had  a  comph'te  septum  ot"  the  \'a^ina  exteniHuL:-  in  tlie 
median  line  from  tlic  vulva  uj)  to  the  ntei-us.  The  two  halves  ot"  the 
va;^ina  were  of  the  same  size,  and  led  each  to  a  vaginal  portion.  Siie 
was  delivered  at  term  ol"  a  male  child  weighing  six  pounds  eight 
oimces.  The  child  ))reseuted  hy  the  hreech  in  the  left  os.  In  the 
he-rinning  of  labor  both  mouths  dilated,  that  of  the  empty  right  side 
even  more  than  the  other,  but  latci-  in  labor  the  right  stayed  at  a  dila- 
tation of  an  inch  in  diameter,  while  the  l(>ft  became  fully  dilated.  The 
labor  lasteil  seventeen  hours  and  three-(piarters,  fifteen  of  which  came  on 
the  first  stage,  two  and  a  (piarter  on  the  second,  and  half  an  hour  on  the 
third.  The  scrotum  having  become  discolored,  the  child  was  easily 
extracted  mamially.  During  parturition  the  vaginal  septum  was  torn 
up  to  a  quarter  of  an  inch  from  the  uterus,  and  ten  days  after  con- 
finement nothing  could  be  felt  of  it.  The  interior  of  the  womb  was 
not  examined  ;  the  external  configuration  was  that  of  a  normal  single 
uterus. 

The  much-vexed  question  of  superfcetaiion  lies  beyond  the  scope  of 
this  work.  Suffice  it  here  to  say  that  the  presence  of  a  double  uterus 
M'ould  materially  facilitate  such  an  occurrence,  for  the  idea  prevailing 
until  quite  recently,  that  ovulation  ceased  during  pregnancy,  has  been 
jM'oved  to  be  erroneous,  and  the  conditions  of  the  unimpregnated  side 
of  the  uterus  are  such  that  even  after  the  third  month,  at  which 
period  superfoetation  is  absolutely  impossible, in  a  single  uterus  on 
account  of  the  development  of  the  ovum,  such  an  event  might  occur 
in   it. 

It  has  been  noticed  in  several  instances  that  women  with  a  double 
uterus  were  uncommonly  broad  of  face  and  body,  showing  a  similar 
disposition  to  lateral  extension  in  the  rest  of  the  body  as  in  the 
uterus. 

VIII.  Atresia  uteri. — In  very  rare  cases  the  utei-us  has  been 
found  closed  at  its  lower  end.  The  occlusion  may  be  seated  at  the  os, 
and  be  due  to  the  mucous  membrane  of  the  vagina,  which  covers  the 
vaginal  portion  totally,  without  leaving  any  hole  open.  In  other 
instances  the  occlusion  is  found  in  the  cervix  itself,  which  may  be 
totally  impermeable,  a  muscular  tissue  identical  Avith  that  of  the  sur- 
rounding parts  being  found  where  normally  the  canal  is  situated.  In 
the  latter  case  the  vaginal  portion  is  small  or  absent.  Atresia  has  been 
found  in  a  tv/o-horned  uterus. 

Menstruation  and  conception  are  of  course  impossible.  By  being 
pent   up   the  menstrual  flow  gives  rise  to  a  distension  of  the  womb 


254 


MALFOBMATIONS   OF  THE  FEMALE  GENITALS. 


formed  of  blood  (Jicematometra^),  which  may  be  changed  to  pus  {pyo- 
metra^),  or  instead  of  blood  a  mucous  fluid  may  collect  (hydrometra^). 
If  the  atresia  affects  a  two-horned  uterus,  one  or  both  horns  may  be 
occluded,  and  consequently  the  fluid  collect  in  both  sides  or  only 
in  one. 

The  explanation  of  the  occurrence  of  congenital  atresia  of  the  cervix 
as  a  malformation  presents  no  difliculty  when  we  remember  that  the 
uterus  is  formed  by  the  fusion  of  the  Miillerian  ducts,  and  that  these 
at  their  first  appearance  are  solid. 

0.  Arrest  of  Development  durestg  Second  Half  of  Intra- 
uterine Life,  or  After  Birth. 

All  the  forms  of  arrested  development  hitherto  considered  are  refer- 
able to  the  first  half  of  gestation.  An  arrest  at  a  later  period  gives 
rise  to  less  marked  variations  from  the  normal  type.  To  this  group 
belong  the  foetal,  the  infantile,  and  the  pubescent  uterus. 

I.  Uterus  fcetalis  and  Uterus  infantilis. — Several  observations 
at  post-mortem  examinations  of  adult  women  have  revealed  the  pres- 


lufantile' uterus  of  a  girl  twenty-one  years  old:  A,  Uterus  and  Appendages  diminished:  a, 
body;  &,  neck ;  c,  c,  tubes;  d,  d,  ovaries;  e,  e,  round  ligaments;  /, /,  broad  ligaments.  B, 
right  ovary  cut  open  longitudinally,  showing  large  Graafian  follicles.  C,  left  ovary  with 
smaller  follicles.    (From  Kussmaul.) 

ence  of  a  uterus  which  not  only  in  size,  but  in  configuration,  corresponded 
to  that  normally  found  in  the  foetus  toward  the  end  of  pregnancy  or  in 
young  children  (Figs.  94,  95).  Sometimes  it  measured  only  an  inch 
or  an  inch  and  a  half  in  length.     In  other  cases  it  attained  the  length 


^  aJfia,  blood  ;  fJ-vrpa^  womb. 
^  vdup,  water  ;  {J^VTpa.,  womb. 


■  "Kvov,  pus ;  firjTpa^  v;omb. 


AJiRKST   OF   DKVELOI'MKST. 


255 


Fig.  95. 


(tl";i  virgin  iitt-rii-..  Imt  cluiractiTi.^tic  wcic  the  |)i(|M)iMlcr;iii(c  nl'  the  ii<'<-k 
over  the  body  and  tlic  tliiniu'ss  of  the  walls.  liittTiially  the  folds  of  the 
arlxir  vitiO  were  cither  eoiifmed  to  the  cervix  or  extcnd(Hl  more  ur  k*ss  up 
into  the  body  of  the  woiiih  (Fi;:;.  !'•'»).  Women  with  .such  a  uterus  rarely 
menstruate,  and  cannot  conceive,  altlKtu^h 
thev  may  have  sexual  aj)|)etite  and  he  well 
fit  for  copulation. 

The  uteriiK  fcetalia  may  at  the  same  time 
he  hironiiH  as  the  residt  of  a  double  arrest 
of  development. 

The  following;  case  of  infantile  uterus  ha.s 
come  under  my  personal  observation.  It 
concerned  a  woman  thirty-six  years  of  age 
who  had  been  marriefl  six  years  and  never 
been  prefrnant.  Her  courses  had  begun 
when  she  was  twenty  years  old,  and  had 
been  painfid  and  very  scant.  She  had 
never  felt  any  sexual  appetite,  although 
coition  did  not  cause  pain,  except  when 
performed  shortly  after  menstruation. 
Before  marriaije  she  was  chlorotic  and  had    coronal  Section  of  the  same  uterus 

,      ,  ,  _^       .       ,  .         .  as  in  Fig.  W,  natural  size:  a,  va- 

nnich  leucorrhcea.  \  aginal  examination  gina;  6,  neck  with  arbor  vitse;  c, 
revealed  a  somewhat  smaller  and  rounder 
OS  than  normal.  The  cervix  was  thin,  but 
about  of  normal  length,  whereas  the  body  was  only  represented  by  a 
small  swelling  like  a  little  finger  w^hich  could  be  felt  both  in  front  and 
behind.  The  depth  of  the  whole  uterine  cavity  from  os  to  fundus 
measured  only  4  centimeters  (If  inches),  leaving  about  1  centimeter 
for  the  cavity  of  the  body, 

II,  Uterus  pubescexs. — Puecli  gave  this  name  to  a  class  of  uteri 
which  are  conformed  like  that  of  the  young  girl  immediately  before 
puberty,  and  especially  characterized  by  their  small  weight,  which  does 
not  exceed  an  ounce,  whereas  the  normal  uterus  averages  an  ounce  and 
a  half.  The  cervix  and  the  body  have  about  the  same  length.^  Men- 
struation is  absent  or  scanty  and  irregular,  and  women  with  so  small 
a  uterus  are  commonly  sterile.  Still,  a  late  development  may  take 
place,  and  they  may  bear  children. 

III.  Uterus  incudiformis,^  s.  biaxgularis. — The  anvil-shaped 

'Even  in  the  arlnlt  nulliparons  woman  the  cavity  of  the  neck  is.  according  to 
Sapiiey  'vol.  iii.  p.  664 1.  longer  tlian  that  of  the  hody,  the  dimensions  being,  on  an 
average,  in  nulliparons  women,  the  whole  cavity.  52  millimeters:  the  neck,  2o ;  the 
isthmii<.  5;  the  body,  22;  in  miiltipnroiis  women,  the  whole  cavity,  57  millimeters;  the 
neck,  24;  the  i,sthmns,  5;  and  the  body,  28.  Others,  throwing  the  isthmus  together 
with  the  body,  come  to  the  opposite  conclusion  (Kussmaul,  p.  18). 

'  Inam.  Latin,  anvil. 


bfjdy;    d.  fundus:   e,  e,  internal 
ends  of  the  tubes. 


256 


MALFORMATIONS  OF  THE  FEMALE  GENITALS. 


Fig.  96. 


uterus  (Fig.  96)  is  well  developed  in  other  respects,  but  the  deficient 

bulging  of  the  fundus,  which 
forms  almost  a  straight  line  from 
one  Fallopian  tube  to  the  other, 
and  the  abrupt  transition  from 
the  neck  to  the  body  of  the  womb, 
give  it  the  shape  of  an  anvil, 
and  reminds  us  of  a  uterus  from 
the  fourth  or  fifth  month  of 
gestation. 

IV.  Uteeus  parvicollis  and 
ACOLLis. — The  body  of  the  uterus 
may  be  well  shaped,  but  the  neck, 
or  at  least  the  vaginal  portion, 
rudimentary  or  absent. 
In  othei'  cases  there  obtains  smallness  of  the  uterus,  with  specially 

defective  development  of  the  neck. 

V.  Anteflexion  is  often  congenital,  and  as  long  as  there  is  only 

an  even  and  moderate  curvature  it  may  be  regarded  as  a  continuation 

of  the  shape  of  the  uterus  in  the  foetus  and  in  young  children. 


uterus  Incudiformis.    (From  Kussmaul,  after 
Oldham.) 


D.  Irregular  Development. 

The  forms  so  far  considered  were  all  reducible  to  an  arrest  of  devel- 
opment. In  others  we  must  admit  a  true  divergence  from  the  normal 
type. 

I.  Obliquity. — There  may  be  a  congenital  crookedness  of  the 
womb  itself,  or  an  otherwise  Avell-shapecl  uterus  may  be  misplaced. 
The  former  condition  is  attributable  to  an  uneven  development  of  the 
two  Miillerian  ducts,  which  combined  go  to  form  the  uterus.  Thus  a 
GongenUal  lateroflexion  is  produced.  A  similar  result  may  be  due  to 
foetal  peritonitis,  with  cicatricial  shrinkage  of  the  broad  ligament  on 
one  side. 

A  well-shaped  uterus  may  be  tilted  over  to  one  side,  especially  where 
there  is  a  beginning  ovarian  hernia. 

II.  Lateroposition. — It  is  not  rare  to  find  in  the  adult  the  womb 
well  shaped,  but  placed  with  its  axis  parallel  to  the  median  line  instead 
of  lying  in  the  same.  This  lateroposition,  when  it  is  not  due  to  pre- 
vious inflammation  and  cicatricial  shrinkage,  is  referable  to  an  uneven 
development  of  the  broad  ligaments. 

III.  Anteposition,  and  IV.  Postposition — that  is,  the  place- 
ment of  an  otherwise  normal  womb  too  far  forward  to  the  symphy- 
sis or  too  far  back  toward  the  sacrum — are  probably  due  to  similar 
irregularities  in  the  development  of  the  surrounding  parts. 


THE  VAC!  IN  A.  257 

V.  TIkrnia  rTF:i{i. — The  uterus  has  been  found  in  a  con^^cuital 
in<j:;uiiial  licruia.  Tliis  irr('<!;ular  position  is  due  to  a  cornpk'ti!  descent 
of  tlie  (t\ai-y  like  that  whieh  is  normal  lor  the  fijenital  gland  of  the 
other  sex.  The  womb  is  then  |)idled  alonj^  until  it  enters  the  hernial 
sac.  In  this  unwonted  ])laee  it  has  even  become  impregnated,  and 
been  subjected  to  Ctesarean  section. 

VI.  Abnormal  Communications. — The  uterus  has  been  found 
forming  one  sac  together  with  the  bladder  and  the  vagina.  It  has 
likewise  been  found  communicating  with  the  bladder  or  the  colon 
ascendens  or  the  rectum.  In  a  case  described  by  Doran  the  right 
side  of  a  uterus  bipartitus  opened  on  the  outer  surfac'c  of  the  body. 


The  Vagina. 

The  vagina  being  originally  one  with  the  uterus,  its  malformations 
are  in  many  respects  similar.  It  may  be  more  or  less  completely  closed 
by  a  transverse  septum  ;  it  may  be  divided  by  a  longitudinal  septum  ; 
it  may  be  too  narrow,  or  it  may  have  faulty  communications  with  other 
cavities. 

Atresia  vagin.e. — The  word  "  atresia  "  is  often  used  by  authors 
in  a  loose  way  in  speaking  of  cases  in  which  the  vagina  was  closed  by 
a  septum  with  a  narrow  opening.  The  etymology  of  the  word,  from 
a  privative,  and  rpdco,  to  bore,  teaches  that  it  ought  only  to  be  apjilied 
to  an  unbored — that  is,  absolutely  closed — vagina.  Where  the  men- 
strual flow  can  find  an  outlet  and  spermatozoids  an  entrance  the  term 
atresia  is  not  appropriate,  but  ought  to  be  replaced  by  stenosis} 

Sometimes  the  atresia  is  only  produced  by  a  membrane  forming  a 
transverse  partition  in  the  vaginal  canal.  The  most  common  kind  of 
this  deformity  is  that  in  Avhich  the  hymen  closes  the  whole  entrance 
(atresia  hymenalis).  It  is  commonly  stated  that  the  hymen  is  formed 
about  the  end  of  the  fifth  month  of  gestation.  If  that  is  correct,  the 
atresia  hymenalis  would  be  an  overgro-wth  ending  in  the  transforma- 
tion of  the  hymen ial  valve  to  a  complete  circle ;  but  perhaps  atresia 
might  be  due  to  a  fusion  of  the  originally  solid  Miillerian  ducts  at 
their  lower  end,  and  the  persistence  of  this  solid  membrane  -without 
the  formation  of  an  opening. 

Breisky  has  found  the  vagina  closed  in  newborn  children  by  a 
tliin  membrane  situated  just  above  the  hymen  {septum  rctrohyme- 
nale). 

A  more  solid  transverse  septum  is  found  in  adults  about  an  inch 
above  the  entrance  of  the  vagina  or  nearer  the  upper  end.  Sometimes 
a  more  extensive  atresia  has  been  found  in  the  middle  between  a  nor- 
mal upper  and  lower  part  of  the  vagina.     As  many  as  three  or  four 

1  Srfvor,  narrow. 
Vol.  I.— 17 


258  MALFORMATIONS   OF  THE  FEMALE  GENITALS. 

transverse  septa  have  been  found  placed  one  above  the  other  and  sep- 
arated by  different  kinds  of  retained  fluid. 

Finally,  the  whole  canal  may  be  absent — a  condition  which  com- 
monly is  combined  with  absence  of  the  uterus ;  but  in  other  cases  a 
normal  uterus  is  found  beyond  the  closed  vagina.  A  case  in  which  the 
former  condition  seemed  to  obtain  has  come  under  my  personal  obser- 
vation, and  was  reported  to  the  ISTew  York  Obstetrical  Society  (Octo- 
ber 7,  1884).  The  patient  was  twenty-one  years  old  and  had  been 
married  ten  months.  She  had  never  menstruated,  but  had  had  monthly 
molimina  for  the  last  two  or  three  years.  She  had  sexual  desire,  but 
had  never  had  any  satisfaction.  She  complained  of  headache  every 
few  days,  general  weakness,  and  slight  constipation.  She  was  strongly 
built,  had  well-developed  breasts,  an  uncommon  abundance  of  black 
pubic  hair  blending  with  a  rich  growth  of  hair  around  the  anus.  The 
urethra  and  the  rectum  were  perfectly  normal.  So  were  the  large  and 
small  labia ;  but  there  was  no  vagina.  In  its  place,  just  behind  the 
meatus  urinarius,  close  up  to  the  median  line,  were  found  two  round 
depressions,  one  on  either  side.  The  left  admitted  a  probe  to  the  dis- 
tance of  one-quarter  of  an  inch ;  the  right  one  was  imperviable.  These 
two  recesses  were  evidently  remnants  of  the  Miillerian  ducts.  Behind 
them  the  fossa  navicularis  yielded  easily  to  pressure,  so  as  to  admit 
a  finger  to  the  depth  of  one  and  a  half  inches.  This  pouch  was  the 
place  in  which  coition  took  place,  and  had  probably  been  expanded  con- 
siderably by  the  act  itself.  There  was  no  tumor  over  the  symphysis. 
In  spite  of  a  very  careful  examination  with  the  index  in  the  rectum, 
a  sound  in  the  bladder,  and  the  other  hand  on  the  abdomen,  no  trace 
of  a  uterus  or  ovaries  could  be  felt. 

In  Gomer  Davies's  case  atresia  of  the  vagina  was  combined  with  a 
cyst  formed  by  distension  of  its  upper  part.  It  was  found  in  a  newly- 
born  child,  in  whom  it  occupied  most  of  the  abdomen.  It  contained 
about  six  ounces  of  a  clear  fluid,  with  grumous  deposit  at  the  bottom. 
The  uterus  sat  at  the  upper  part  of  the  cyst,  communicating  with  it. 

Complete  atresia  excludes  menstruation,  and  may  give  rise  to  the 
accumulation  of  blood  (Jicematooolpos)  or  pus  (pyocolpos)  in  the  vagina 
above  the  septum  or  in  the  uterus.  Atresia  prevents  impregnation, 
and  renders  a  normal  connection  difiicult  or  impossible.  If  there  is 
only  a  transverse  septum  in  the  upper  part  of  the  vagina,  the  relations 
approach  the  normal  condition.  If  it  is  situated  near  the  lower  end  or 
at  the  entrance,  the  pouch  may  in  course  of  time  become  considerably 
deeper.  Sometimes  connection  takes  place  in  one  of  the  neighboring 
openings,  the  urethra  or  the  anus,  especially  the  former.  The  urethra 
is  in  some  women  very  easily  dilatable.  I  examined  once  an  intact 
virgin  in  whom  the  entrance  had  not  been  made  easy  by  masturbation, 
as  often  is  the  case,  and  I  was  much  surprised  to  find  that  my  index, 


Tin-:  ^.l^7.v.l.  250 

;iltlittiii:li  Mot  cxcrclsiiii;-  more  than  a  \(iy  iiHMlcratc  prt'ssiirc,  had  pciic- 
tratctl  into  the  l)la(l«l('i\  Rctraciiin-  my  steps,  I  f'oimil  iimch  more  n-sist- 
aiict'  ill  I'litci'iiin'  the  vauina,  ahhoii^h  this  oruaii  |)rov('(l  to  he  ciitii'dv 
normal.  This  is  |>rol>al»ly  a  rare  condition:  I  at  lra>t  have  oidy  met 
with  tliis  sinii'lc  case.  lint  l)y  rc|)catc»l  attcm|)ts  at  coition  in  cases  (jf 
ocrhision  of  tlie  vaiiina  the  nrethra  Ix'comes  ol'tcn  <:r:i<hially  dihited,  so 
as  to  admit  the  male  meml)er;  and,  strant;'e  enoniih,  this  considerable 
dihitation  ivsnlts  only  exceptionally  in  incontinence  ut"  nrine.  As  a 
rnle.  it  does  not  uive  rise  to  any  snch   troui)le. 

Much  moi'c  common  tlian  complete  atresia  are  the  cases  of  nteiw.sis 
produced  l)v  a  more  or  less  complete  septum  with  one  or  more  oj)en- 
iugs.  Such  an  opeiiinii;  is  sometimes  so  small  that  it  can  only  he  dis- 
covered at  the  time  of  menstruation,  when  perhaps  softeninjr  takes 
place;  and,  at  all  events,  the  blood  trickliui;-  tlirouuh  the  openin<;  leads 
to  its  discovery.  Even  under  so  unfavorable  circumstances  spermata- 
zoids  may  work  their  way  into  the  interior  of  the  womb  and  pregnancy 
take  place.  The  membrane  will  then,  of  course,  form  an  obstruction 
to  delivery,  and  re([uire  operative  interference,  as  in  the  cases  of  I,  E. 
Taylor,  J.  S.  Coleman,  F.  Barnes,  Heywood  Smith,  and  others. 

Different  theories  have  l)een  proposed  for  explaining  the  occurrence 
of  a  transverse  septum  in  the  vagina.  One  is  that  after  the  ^liillerian 
ducts  had  been  perforated,  and  had  been  fused  together  into  one  canal, 
an  agglutination  and  coalescence  took  place  between  the  two  walls. 
According  to  another,  the  septum  is  looked  upon  as  a  remnant  of  the 
originally  solid  filaments,  which  have  coalesced,  but  failed  to  be  tun- 
nelled at  the  seat  of  the  membrane.  Finally,  where  there  is  only  one 
more  or  less  thick  septum,  it  may  be  that  the  canal  above  the  septum 
belongs  to  one  Miillerian  duct,  and  that  below  to  the  other. 

Double  Vagina. — Like  the  uterus,  so  the  vagina  may  be  divided 
into  two  halves  by  a  longitudinal  partition.  It  is  composed  of  two 
layers  of  mucous  membrane  and  intervening  muscular  tissue.  It  may 
be  complete  or  inc(jmplete.  In  the  latter  case  it  may  be  found  in  the 
upper  part  or  in  the  lower  or  in  the  middle,  or  be  perforated  by  one  or 
more  holes. 

When  the  vagina  is  double  the  uterus  is  commonly  so  too,  but  in 
rarer  cases  a  double  vagina  may  correspond  to  a  single  uterus.  One- 
half  of  the  vagina  is  often  more  developetl  than  the  other.  Where 
there  is  a  one-horned  uterus  combined  with  a  double  vagina,  that  side 
which  corresponds  to  the  atrophied  or  absent  uterine  horn  remains 
rudimentar}^  Sometimes  there  corresponds  only  one-half  of  the 
vagina  to  a  one-horned  uterus,  the  other  half  being  absent  altogether. 
In  tliis  case  the  vagina  is  very  narrow. 

When  a  double  vagina  corresponds  to  an  entirely  double  uterus 
(bicoi'nis  duplex  or  septus),  as  a  rule  there  is  a  separate  vaginal  portion 


260  MALFORMATIONS  OF  THE  FEMALE  GENITALS. 

in  each  half  of  the  vagina.  As  we  have  seen  above,  there  has  excep- 
tionally been  found  a  single  cervical  portion  with  two  openings  in  one 
half  of  the  vagina  and  none  in  the  other.  One-half  of  the  vagina 
may  be  too  narrow  for  coition,  and  the  one  that  is  used  may  end  as  a 
cul-de-sac  without  communication  with  the  womb. 

Instead  of  a  more  or  less  complete  vaginal  septum,  there  may  only 
be  found  a  band  uniting  the  anterior  with  the  posterior  wall  in  the 
median  line.  I  have  seen  such  a  case  myself,  in  which  there  was  a 
fleshy  band  as  thick  as  a  finger  just  below  the  vaginal  portion.  As  it 
obstructed  labor,  I  cut  it  with  scissors.  There  was  no  bleeding.  In 
another  case  under  my  care  the  husband  complained  of  some  obstruc- 
tion to  the  introduction  of  the  penis.  On  examination  I  found  on  the 
left  side  of  the  upper  half  of  the  vagina  a  septum  one  and  a  half  inches 
high  and  three-quarters  of  an  inch  wide.  Between  it  and  the  vaginal 
wall  there  was  a  free  passage.  This  septum  was  likewise  cut  with  scis- 
sors, which  gave  rise  to  some  little  hemorrhage.  As  the  lady  had  borne 
a  large  child  before,  and  the  dyspareunia  had  appeared  after  the  birth 
of  the  child,  it  is  not  unlikely  that  this  septum  was  only  a  remnant 
of  a  more  complete  one  which  had  been  partially  destroyed  during 
parturition. 

Double  vagina  may  be  combined  with  atresia  on  one  or  both  sides, 
and  thus  unilateral  or  bilateral  hsematocolpos  or  pyocolpos  may  be 
produced. 

Stenosis,  or  narrowness  of  the  vagina,  may,  as  we  have  seen  above, 
be  due  to  the  presence  of  an  incomplete  transverse  septum,  or  to  the 
vagina  being  really  only  half  a  vagina.  By  an  arrest  of  development 
in  childhood  and  later  it  may  likewise  stay  narrow — a  condition  which 
sometimes  is  combined. with  the  insufficient  development  of  the  uterus 
described  above  as  uterus  fcetalis  and  uterus  infantilis. 

Blind  Canals. — Immediately  above  the  entrance  to  ihe  vagina,  on 
one  side  of  the  columna  rugarum,  are  sometimes  found  openings  leading 
into  canals  lined  with  mucous  membrane,  but  with  smooth  walls  extend- 
ing upward  parallel  to  the  vaginal  wall  or  deviating  into  the  peri- 
vaginal connective  tissue.  They  may  be  an  inch  and  a  half  long  and 
thick  enough  to  admit  the  little  finger.  The  upper  end  is  closed.  These 
canals  are  supposed  to  be  uncommonly-developed  lacunae  of  the  mucous 
membrane.  They  differ  from  a  secondary  vagina  by  their  thin  and 
smooth  wall,  and  sometimes  by  their  direction  (Breisky). 

Faulty  Communications. — When  we  remember  that  at  an  early 
stage  of  foetal  development  there  is  a  common  cloaca  in  which  end  the 
urinary  and  genital  canals,  as  well  as  the  rectum  (see  Fig.  2,  p.  69  ; 
Figs.  31  and  32,  p.  89),  it  is  easy  to  understand  how  by  an  arrest  of 
development  faulty  communications  may  be  found  between  the  differ- 
ent passages. 


Tiir.  VAciyA. 


2(n 


Normally,  the  rectum  is  scpai'atcil  \'vuu\  the  simis  iiroM^cnitalis  hv  tlic 
formation  oi'  u  st'ptum  wliidi  is  <'oiii|)l(t('(l  in  tlic  tnitii  week.  Il"  this 
is  not  formed,  tlie  rectum  will  a|»|»ar<iitly  open  into  the  vajjina,  ami 
tlicrc  will  be  atresia  arii — a  eouditioii  wliicli  lias  hccii  dcsiirnatcd  hv  tlie 
stranjije  name  of  atresia  ani-raf/hia/i.s.  What  ha.s  l>een  taken  for  tlie 
vau;ina  is  really  the  cloaca,  which  has  not  been 
divided  into  a  rectal  and  a  urou;('nital  |)art  (|K'r- 
sistent  cloaca,  Fig.  97).  Sometimes  the  opening 
of  the  rectum  has  a  sphincter,  so  that  the  individual 
may  retain  the  feces  voluntarily.  This  apparent 
communiciition  with  the  vagina  is  not  very  rare.  Persistent  (;ioa< a:  r.  <io- 
Dr.  J.  H.  Pooley  of  this  city  ha.s  compiled  38  cases,     ougiit  to  have  forme<i 

the  r>erineuin ;  ]i,  ree- 
tum ;  y,  vagina;  //, 
bladder,  U,  urethra. 
(From  Schroeder.) 


She   menstruatwl 


In  other  cases  it  is  the  genital  canal  which  seems 
to  open  into  the  normally-formed  rectum.  The 
celebrated  French  surgeon  Louis  has  reported  the 
case  of  a  girl  whose  genitals  were  imperforate, 
through  the  anus,  and  through  the  same  opening  coition  took  place, 
and,  finally,  a  child  at  full  term  was  born  that  way.  In  this  case 
either  the  vagina  or  the  uterus  must  have  opened  into  the  rectum.  It 
is  not  stated  where  the  urethra  opened,  but  there  can  scarcely  be  anv 
doubt  that  that  organ  likewise  opened  inside  of  the  only  opening 
present. 

A  similar  faulty  communication  may  take  place  between  the  vagina 
and  the  bladder  or  the  urethra.  At  first  the  sinus  urogenitalis  appears 
a.s  a  continuation  of  the  bladder,  but  in  consequence  of  the  growth  of 
the  uterus  and  the  vagina  in  the  sixth  month,  and  the  comparatively 
slow  development  of  the  sinus  urogenitalis,  it  appears  finallv  as  the 
continuation  of  the  vagina,  forming  the  vestibule  into  which  the  urethra 
opens  (Fig.  33,  p.  90).  Some  cases  present  an  appearance  as  if  the 
urethra  did  not  open  into  the  \Tilva,  but  into  the  vagina  itself.  A  closer 
examination  will,  however,  reveal  that  this  condition  is  due  to  an  un- 
common depth  and  narrowness  of  the  sinus  urogenitalis,  so  that  what 
appears  to  be  the  vagina  is  really  the  vestibule  (per- 
sistent sinus  urogenitalis ;  Fig.  98). 

In  Palfyn's  case  there  was  one  sac,  into  which 
opened  a  uterus  didelphys  and  the  intestine. 

In  cases  of  extroversion  of  the  bladder  the  vagrina, 
as  well  as  the  ileum  and  the  colon,  have  been  found 
to  open  on  the  exposed  raucous  membrane.  In 
Lel)edeff' s  case  there  was  a  congenital  vesico-vagi- 
nal  fistula  combined  with  hypospadias. 

W.  H.  Baker  of  Boston  has  described  and  suc- 
cessfully operated  on  a  case  in  which  the  left  ureter 
opened  into  the  vagina,  instead  of  being  connected  with  the  bladder, 


Fig.  OS. 


Persistent  Sinus  Uro- 
grenitalis:  C  hyper- 
trophic clitoris;  B, 
bladder;  I',  ure- 
thra: V,  vagrina;  .•<, 
sinus  urogenitalis; 
R.  rectum.  (From 
Schroeder.) 


262  MALFORMATIONS   OF  THE  FEMALE  GENITALS. 

The  Hymen. 
The  hymen  is  not,  as  stated  in  most  anatomical  textbooks,  a  semi- 
lunar fold  of  the  mucous  membrane  placed  at  the  entrance  of  the 
vagina.  It  is  now,  as  stated  above,  looked  upon  as  being  the  whole 
lower  end  of  the  vagina,  and  its  shape  varies  very  much.  As  a  full 
knowledge  of  the  normal  shape  of  the  hymen  is  of  great  practical 
value  in  legal  questions,  we  will  give  some  details  on  this  subject. 
Tardieu,  who  has  examined  more  than  600  cases  with  special  reference 
to  the  hymen,  admits  five  normal  conformations,  which  he  places  in  the 

following  order  of  decreasing  frequency  : 

•^  1.  The  hymen  consists  of  a  strip  of  tissue 

^S|     \^  bent  at  the  lower  end  so  as  to  form  two 

£    .^^m^^:-      %  lateral   lips,  touching  one  another  in   a 

m    ^^V^^\      1  vertical  line ;  which  shape  is  almost  con- 

M    W£'|W|    S  stantly  found  in  childhood,  and  sometimes 

S    ^  ^  I '  -  ^   I  M.  yet  after  puberty  (Fig.  99,  from  Tardieu), 

\  -'   ^ '  2.  The  hymen  forms  an  irregularly  circu- 

"^^^^^^B"  ^^^  diaphragm  with  a  more  or  less  large 

i^^^^K  opening  in  the  anterior  third  (hymen  an- 

--.z  1^^^^^^^^^^^^^^  nularis)}     3.  The  diapliragm  is  exactly 

''  — ^=^^     ^^^^^^^fe    circular,  with  a  central  circular  opening 

(hymen  circularis).  4.  The  diaphragm 
is  crescent-shaped,  with  a  concave  border  turned  forward,  and  two 
horns  ending  on  the  inside  of  the  labia  minora  (hymen  semilunaris).^ 
5.  The  hymen  is  only  represented  by  a  low  circular  or  semilunar  ridge. 
Besides  these  normal  shapes  the  hymen  presents  several  abnormalities. 
According  to  Dohrn,  an  intact  hymen  may  present  indentations.  In 
the  hymen  denticulatus  the  edge  does  not  form  one  smooth  line,  but  is 
divided  into  many  prominences  by  short  nicks.  It  is  distinguished 
from  a  ruptured  hymen  by  the  softness  of  the  edge,  the  round  contour 
of  the  prominences  and  recesses,  and  the  absence  of  cicatricial  tissue. 
The  hymen  fimhriatus  has  the  edge  split  into  a  fine  fringe,  due  to 
papillary  hypertrophy,  but  similar  growths  are  then  found  on  the  sur- 
faces of  the  hymen,  on  the  labia  minora,  and  round  the  urethra. 

It  is  doubtful  if  the  hymen  is  ever  absent.  At  least  Tardieu  has 
never  seen  a  case  in  which  there  were  not  distinct  remnants  of  it,  but 
the  last-mentioned  shape,  where  the  hymen  is  reduced  to  a  scarcely 
prominent  ring,  can  easily  be  mistaken  for  total  absence. 

Atresia  hymenalis. — The  hymen  may  form  a  completely  closed 
septum.  This  condition,  like  that  of  the  presence  of  a  diaphragm 
higher  up  in  the  vagina,  will  cause  retention  of  the  menstrual  flow  as 
a  tarry  mass  (hcematocolpos),  or  the  accumulated  fluid  may  suppurate 
(pyocolpos). 

^  Annvlus,  ring.  ^  Semi,  half;  luna,  moon. 


THE  IIYMES.  263 

Abnormal  Openings. — In  otlu-r  cajH^  the  hymen  has  two  ruimd 
or  IfiiiTthv  iijK'nin^s  (hi/mcn  hij<tris^  or  bifnutttrntux)}  If  the  <»jm'|i- 
inifs  arc  lar>io  and  the  iiitcrvcniii^  tissiu*  narrow,  the  case  is  caMe*! 
hipiufi  septus.  Sometimes  the  partition  ji;rows  out  from  tht-  ant<'rior 
ami  j>ostorior  circiiinfcnMU'o,  hut  without  joiuin<r  in  the  niiddlc  (/n/iiwn 
giihsijifn.s). 

Till'  hymen  may  likewise  be  perforated  by  many  small  openings 
{Jitliiu'ii  cribriform  /.v  ).^ 

FLh>^HY  Hymen. — The  normal  hymen  eon.«ists  of  a  dftuMc  layer 
of  MUK'ous  membrane  with  an  intermediate  layer  of  mu.s<"ular  fibres 
and  many  blood-vessels.  In  abnormal  ca<es  this  intermediate  layer 
may  become  so  much  developeil  as  to  present  a  serious  obstacle  to 
connection. 

Double  Hymen. — The  hymen  may  be  said  to  be  double  in  ditieivnt 
senses.  Sometimes  it  is  composed  of  two  diaphragms  pla<;ed  (^ne  alcove 
the  other,  but  the  upper  one  in  such  cases  is  probably  a  traasverse  sep- 
tum near  the  lower  end  of  the  vagina.  Sometimes  this  c<jndition  is 
due  to  accumulati<jn  of  mucus  above  the  hymen,  producing  a  dilatation 
of  the  lower  end  of  the  vagina,  limited  above  by  a  constriction,  at  the 
seat  of  which  the  second  hymen  is  developed. 

Where  the  vagina  is  (l(juble  there  is  generally  a  hymen  in  each  half, 
but  often  the  lower  part  of  one-half  of  the  vagina  may  be  absent,  so 
that  the  canal  ends  blind  without  any  hymen.  Such  a  condition  will 
give  rise  to  the  formation  of  a  lateral  collection  of  blood  or  other 
fluid. 

Finallv,  the  hvmen  alone,  in  an  otherwise  sinofle  vagina,  mav  Ije 
separated  in  two  by  a  septum  running  in  an  antero-posterior  direction. 
(See  Hi/men  septus.) 

CoN( GENITAL  Cysts. — Barstellberger  has  described  a  cyst  of  the  size 
of  a  lentil  in  the  hymen  of  a  newborn  girl.  Microscopical  examination 
showed  that  it  had  been  formed  by  invagination  from  the  epithelium  on 
the  vulvar  side  of  the  organ. 

The  Hymen  in  the  Xegro  Race. — Is  there  any  difference 
between  the  white  and  the  black  woman  as  to  the  place  of  the  hymen  ? 
Dr.  E.  B.  Turnipseed  of  Columbia,  S.  C,  asserted  some  years  ago  that 
the  hymen  in  the  negress  was  situated  from  one  and  a  half  to  two 
inches  "  above  the  entrance  of  the  vagina."  He  gave  the  details  of 
nine  cu'ses,  seven  of  which  were  in  children  eight  to  twelve  years  old, 
in  whom  the  distance  was  from  a  half  to  three-f[uarters  of  an  inch 
above  the  entrance.  This  assertion  was  corroborated  by  Dr.  C.  H. 
Fort  of  Adams  Station,  Tennessee.  He  gives  six  cases.  It  is  claimed 
that  the  hymen  in  these  cases  was  situated  one  or  two  inches  "within 
the  vulva."     The  latter  author  claims  likewise  that  the  hymen  of  the 

*  Bis,  twice ;  /oris,  door.  *  Feneslra,  window.  '  Vribrum,  sieve. 


264  MALFORMATIONS   OF  THE  FEMALE   GEXITALS. 

negress  is  of  greater  density  than  that  of  the  -white  ^\■oman.  He  thinks 
that  these  two  features,  the  high  position  and  the  unusual  density, 
"  woidd  enable  any  practised  physician  to  distinguish  the  negro  from 
the  white  race,  even  in  the  dark,  by  aid  of  touch  alone."  On  the  other 
hand,  Dr.  H.  O.  Hyatt  of  Kinston,  X.  C,  claimed  to  have  examined 
a  thousand  negro  women  without  remarking  any  difference  between  the 
fru^o  races  in  regard  to  the  vagina  and  hymen.  He  thinks  the  assertion 
of  Dr.  Turnipseed  is  based  on  a  confasion  of  the  rectilinear  rima  puden- 
di  and  the  round  orificium  vaginje.  I  have  no  personal  experience  on 
this  question  to  oifer.  Dr.  Hyatt  is  right,  that  the  lower  and  upper 
openings  of  the  vulva  are  very  often  confounded,  as  I  have  pointed  out 
myself  in  the  anatomical  remarks  forming  the  introduction  to  my  paper 
on  the  "  Obstetric  Treatment  of  the  Perineum ;"  but  even  if  the  two 
above-named  observers  should  have  made  this  mistake,  that  could  not 
account  for  much  more  than  one  inch,  and  by  no  means  for  the  distance 
of  two  inches  which  they  claim  in  some  cases.  Besides,  it  is  not  likely 
that  they  would  claim  as  a  peculiarity  for  the  negro  race  what  they  could 
scarcely  be  otherwise  than  familiar  with  in  the  white  race.  If  their 
observation  is  correct,  the  explanation  can  only  be  that  the  sinus  uro- 
genitalis  is  deeper  in  the  black  race.  It  would  be  very  desirable  that 
Southern  practitioners,  who  have  a  larger  field  of  observation  in  this 
regard  than  we  who  live  in  the  Xorth,  warned  as  to  the  possible  mis- 
take pointed  out,  would  pay  attention  to  this  interesting  anthropologi- 
cal cj^uestion,  and  give  us  a  large  number  of  exact  obser%*ations  of  the 
seat  of  the  hymen  in  the  negro  woman. 

As  to  the  theory  of  the  malformations  of  the  hymen,  it  must  be 
remembered  from  the  section  on  Development  (p.  92)  that  this  organ 
is  formed  late  in  foetal  life,  beginning  in  the  nineteenth  week,  at  a  time 
when  the  Miillerian  ducts  long  ago  have  opened  into  the  sinus  urogeni- 
talis  and  been  fused  together  into  one  canal.  The  atresia  of  the  hymen 
can  therefore  not  be  explained  as  an  arrest  of  development,  like  that 
which  obtains  when  the  same  condition  is  found  higher  up  in  the 
vagina  or  in  the  uterus,  but  it  must  be  looked  upon  as  an  excess  of 
growth.  iSTor  can  the  double  hymen  simply  be  taken  as  an  arrest  of 
development  of  the  hymen  itself,  but  must  be  regarded  as  an  arrest  of 
development  of  the  lower  end  of  the  IMullerian  ducts,  by  which  there 
stays  two  openings,  and  the  subsecpient  development  of  a  hymen  in 
each  of  them.  ^Multiplicity  of  openings  must  be  looked  upon  as  the 
result  of  an  irregular  2:ro's\i:h. 


The  Vulva. 

Absence  of  Vitlva. — The  whole  of  the  external  genitals,  together 
with  the  anus,  may  be  absent,  a  continuation  of  the  skin  without  any 


THE   VULVA. 


265 


oponiii!2;s  ocfnpvinjj:;  their  place.  This  coiKlitioii  is  (hio  to  an  arrest  of 
(level* >|niient  at  the  \vv\  earliest  period  of"  tJetal  (levelopiiieiit,  before 
the  appearance  ol"  the  cloacal  opciiiiii^-  in  the  ("oiirth  wi-eU.  It  is  almost 
always  coml)iiU'(l  with  an  arivst  ol"  (h'\-clopiiiciit  in  other  orj^aiis,  and  is 
onlv  f'onnd  in  non-viahle  fJetnses. 

Ill  other  cases  there  is  an  aims,  hut  the  vnl\a  has  not  hecn  formcnl, 
the  li'enital  f"iirr()W  having  not  become  deep  enou«ih  to  <»pen  into  the 
sinus  urogenital  is. 

Hypospadias.' — AVhen  the  posterior  wall  of  the  urethra  is  defective 
the  condition  is  called  hypospadias  (Fig.  100).  If  the  defect  extends 
lar  up,  the  control  over  the  bladder  is  lost. 


Fir;.  100. 


Hypospadias:  a,  open  canal,  fijrmed  by  the  anterior  wall  of  the  urethra,  the  posterior  being 
absent  in  this  part;  b,  posterior,  closed  part  of  the  urethra;  d,  hymen;  e,  opening  in  the 
same.    (From  Wlnckel,  after  Mosengeil.) 

Epispadias ^  is  the  name  for  a  condition  in  -uliich  there  is  a  cleft  in 
the  anterior  wall  of  the  urethra,  which  mostly  is  combined  with  a  cleft 
in  the  anterior  wall  of  the  bladder  (extroversio  vesicce).  In  the  upper 
part  of  the  vulva,  just  below  the  symphysis  pubis,  appears  the  mucous 
membrane  of  the  open  bladder  (Fig.  101).  There  is  no  urethra.  The 
clitoris  may  be  cleft. 

The  urethra  forms  originallv  one  organ  with  the  bladder.  Both  are 
a  development  of  that  part  of  the  allantois  which  is  situated  inside  of 
the  foetus.  Thus  this  cleavage  is  not  a  simple  arrest  of  development, 
but  is  attributable  to  a  deficiency  of  the  anterior  wall  of  the  bladder, 
as  well  as  to  an  arre.st  of  development  in  the  abdominal  wall. 

1  'Yrro,  under ;  c~a6ucj,  I  tear.  ^  'E-i,  on  ;  ryKadi^i^,  I  tear. 


266 


MALFORMATIONS  OF  THE  FEMALE  GENITALS. 
Fig.  101. 


Epispadias:  a,  fissure  In  the  bladder;  b,  labium  majus;  c,  clitoris;  d,  labium  minus;  e,  hymen; 
/,  vaginal  entrance.    (From  Winckel,  after  Kleinwachter.) 

The  clitoris  has  been  found  cleft,  without  any  cleavage  of  the  urethra 
or  bladder,  but  combined  with  a  cleft  symphysis  and  a  deficiency  in  the 
abdominal  wall  above  the  bladder. 


Other  Congenital  Abnormities. 

The  clitoris  may  be  absent,  rudimentary,  or,  on  the  other  hand,  very 
much  enlarged.  Hyrtl  states  that  in  some  African  tribes  the  clitoris 
hangs  down,  covering  the  rima  pudendi  as  a  valve,  and  that  the  people 
fasten  it  with  a  ring  to  the  perineum  as  a  protection  for  virginity.  In 
hermaphrodites  it  often  becomes  as  large  as  a  penis  of  moderate  dimen- 
sions. Bainbridge  found  in  a  woman  whom  he  assisted  in  labor  a  cli- 
toris about  five  inches  long  and  of  the  diameter  of  a  quiescent  j)enis  of 
an  adult,  to  which  organ  it  became  still  more  like  by  the  presence  of  a 
groove  behind  the  glans.  At  a  later  examination  it  was  found  measur- 
ing three  inches  in  length  and  two  in  circumference. 

The  labia  minora  may  likewise  be  absent  on  one  or  both  sides. 


iiEnMAriiiinDisM.  207 

There  tnay  1k'  found  iuiir,  or  t-veii  six,  tliif  to  a  loldiii;^  <»f'  the  (-(lifcs 
(tf  the  <i;('iiital  iiirrow.  Soinctiiiies  the  hibia  minora  arc  iiinrh  loiiir«'r 
than  nsual,  which  peculiarity  is  ionnd  eonstantly  in  Hottentot  women 
and  has  hci-n  caUed  the  Jlolfnilol  (ipion.  These  fhij)S  are  said  to  oWtain 
a  lenjith  ot"  eight  or  twelve  inches.  \\\  some  tribes  they  are  regularly 
eut  away  by  ti  kind  ot"  eircumcisitjn. 

The  labia  majora  are  more  rarely  the  seat  ol"  a  similar  c<jngenital 
hypertrophy. 

Atresia  vulixe  supa^fidaliK. — The  labia  majora  as  well  as  the  labia 
minora  may  in  the  second  half  of  ffctal  life  l)ecome  agglutinated,  and 
coalesce  more  or  less  extensively  from  behind  forward,  so  as  to  give 
the  appearance  of  an  uncommonly  long  perineum.  It  is  rare  that  the 
nymplue  are  grown  together  to  such  an  extent  as  to  prevent  urination 
in  the  newborn  child.  Menstruation  is  unimpeded,  but  the  dimensions 
of  the  entrance  may  be  so  small  as  to  oppose  a  serious  obstacle  to  sexual 
connection  unless  it  be  removed  early  in  life. 

Vuh-a  infantilis. — By  an  arrest  of  development  after  the  birth  of  the 
child  the  vulva  may  retain  in  the  adult  the  small  dimensions  of  child- 
hood. If,  nevertheless,  impregnation  takes  place,  the  condition  may 
give  rise  to  difficulties  in  childbirth. 


Hermaphrodism.  ^ 

Considerable  practical  no  less  than  scientific  interest  attaches  to  that 
group  of  malformations  which  are  designated  by  the  term  "  hermaph- 
rodism "  or  "  hermaphroditism ;"  that  is,  the  condition  in  which  the 
characteristics  of  the  two  sexes  become  more  or  less  blended  in  one 
individual. 

The  physician  may  have  to  decide  at  the  birth  of  a  child  to  what 
sex  it  belongs — a  decision  which,  if  hastily  made,  may  lead  to  the 
gravest  consequences  and  cause  much  unnecessary  suffering,  and  Avhich 
often  cannot  be  made  at  all  without  an  examination  of  the  inner  parts, 
as  in  Sippel  and  Chalmers's  cases,  where  the  child  to  all  appearances 
was  simply  a  male  hypospadiaeus,  while  the  autopsy  revealed  a  perfect 
uterus,  ovaries,  tubes,  broad  and  round  ligamenis.  If  there  is  any 
doubt  alx)ut  the  sex  of  a  child,  I  think  I^awson  Tait's  advice  is  a  good 
one — to  bring  the  child  up  as  a  male.  AVhen  it  grows  up  it  will  find 
out  that  it  is  not  formed  like  other  boys,  and  when  grown  to  manhood, 
if  unfit  to  perform  the  functions  of  the  male,  it  will  abstain  from  mar- 
riage.    Girls  are  often  in  an  astounding  degree  ignorant  of  everything 

^  Hermaphroditus,  a  son  of  Hermes  (^or  Mercury)  and  Aphrodite  (or  Venus),  accord- 
ing to  Grecian  mytholoffv,  became  the  object  of  the  amorous  desires  of  the  nymi)h 
Salmacis,  who  induced  the  gods  to  make  them  one  body,  retaining  the  characteristics 
of  both  sexes. 


268  MALFORMATIONS   OF  THE  FEMALE   GENITALS. 

belonging  to  sexual  relations.  An  hermaphrodite  brought  up  as  a  girl 
may,  therefore,  marry  without  having  any  idea  of  being  unfit  for  sexual 
connection,  or  the  male  instincts  may  awake,  and  the  male  hermaphro- 
dite, being  brought  up  among  girls,  and  placed  in  positions  where  the 
instincts  can  be  satisfied,  much  mischief  may  be  done,  as  in  the  case  of 
Madelaine  Mugnoz,  the  nun  of  Ubeda,  who  suffered  death  for  rape.  It 
is  so  much  wiser  to  follow  this  advice  as  the  possibilit}'-  of  erring  by  so 
doing  is  much  smaller,  male  hermaphrodites  being  much  more  common 
than  female. 

Important  medico-legal  questions  attach  to  the  question  of  hermaph- 
rodism.  Often  males  only  inherit  certain  estates,  and  it  may  becouie 
necessary  to  decide  if  the  heir-apparent  ftilfils  the  necessary  require- 
ment as  to  sex.  In  the  United  States  the  right  of  voting  as  a  citizen 
and  of  filling  certain  offices  is  restricted  to  the  male  sex,  and  conse- 
quently a  man's  right  to  do  so  may  be  challenged  on  account  of  doubt- 
ftil  sex.  Hermaphrodism  may  be  claimed  as  entitling  to  divorce,  or 
the  question  may  come  up  whether  a  child  can  be  the  offspring  of  an 
hermaphrodite  or  not. 

Klebs's  division  of  the  different  kinds  of  hermaphrodism  recom- 
mends itself  by  its  clearness,  completeness,  and  practical  value,  and  is 
therefore  a  valuable  guide  which  we  will  follow.^  This  author  dis- 
guishes  first  true  from  spurious  hermaphrodism.  As  true  hermaph- 
rodism only  such  cases  are  recognized  in  which  a  testicle  and  an  ovary 
are  found  in  the  same  individual.  Under  the  term  spurious  hermaph- 
rodism he  unites  all  those  cases  in  which  the  genital  glands  belong  to 
one  sex  and  the  external  organs  and  internal  ducts  approach  more  or 
less  the  type  of  the  other  sex. 

From  the  history  of  development  we  know  that  the  genitals  are  com- 
posed of  three  different  parts  :  first,  the  sexual  glands  ;  second,  the  two 
sets  of  ducts  (the  Wolffian  ducts,  which  are  transformed  to  the  tail  of 
the  epididvmis  and  the  vas  deferens ;  and  the  Mullerian  ducts,  which 
form  the  Fallopian  tubes,  the  uterus,  and  the  vagina) ;  and  third,  the 
external  genitals.  These  three  portions  having  each  its  own  inde- 
pendent foundation,  we  can  understand  how  one  of  them  may  become 
developed  according  to  a  different  t}'pe  from  the  others. 

True  Hermaphrodism,  or  Androgynia  {Her7}iaphrodismus 
vents). — This  group  comprises  only  the  cases  in  which  a  testicle  and 
an  ovary  are  found  in  the  same  individual.     This  condition  is  normal 

1  The  commonly- followed  system  distinguishes  between  spurious  and  true  hermaph- 
rodism. In  the  first  class  are  only  placed  slight  cases,  such  as  hypospadias,  enlarged 
clitoris,  atresia  of  the  vulva,  etc.,  which  we  exclude  all  together.  The  second  com- 
prises three  groups :  1,  Lateral  hermaphrodism,  where  there  is  a  testicle  on  one  side,  an 
ovary  on  the  other ;  2,  vertical  or  double  hermaphrodism,  where  on  the  same  side  are 
found  male  and  female  organs ;  3,  transverse  hennaphrodism,  where  the  internal  organs 
are  male,  the  external  female. 


ni:i:M.  i  rnnonisM.  !>(;!> 

in  iiiaiiv  Inwcr  aiiliiials,  ami  is  (tccasi(Hially  rniiiid  in  the  liit;lic>(.  Its 
existi'iicc  ill  mail  is  yet  denied  by  iiiaiiy,  and  most  of  the  (dder  eases 
ar(>  not  reliaMe.  Only  those  can  eoniit  in  which  a  mieroseoj)ieal  exam- 
ination \ields  a  |»ositi\-e  I'esnll.  It  has  hecii  claiiiiccl  that  hoth  testidos 
and  holli  ovaries  ha\'e  heeii  I'oiind  in  one  individual  {fmr  hllitl<r(tl  licr- 
iixi/ihrodistii)  ;  ami  I  tliinU  IIe|)|iiier's  ease  is  one  in  j)oiiit.  Inthehodv 
ol'  a  rhild  that  die<l  at  the  age  of  two  months  he  found  (a)  an  orj^an 
which  with  the  same  ri*>;ht  can  be  called  a  liypos])adie  penis  and  a 
liypertrophied  clitoi'is;  (6)  a  cleft  serotnm  ;  (r-)  a  sinns  nrogenitalis  and 
Rosen  mil  Iter's  oiuan  representing  parovarium  and  epididymis;  further- 
more, a  ])rostate  and  both  testicles;  and,  finally,  a  vagina,  uterus,  tubes, 
both  ovaries,  round  and  broad  ligaments.  The  microscopical  examina- 
tion showed  the  ovary  to  l)e  full  of  Graafian  follicles,  some  of  which 
contained  an  ovum,  while  the  testicle  was  composed  of  seminal  canals. 
It  seems  that  this  most  imjiortant  case  has  been  overlooked  by  Klebs, 
since  he  does  not  even  allude  to  it. 

It  has  likewise  been  asserted  that  on  one  side  there  may  be  one 
sexual  gland,  either  a  testicle  or  an  ovary,  and  on  the  other  both 
a  testicle  and  an  ovary  (true  unilateral  hermaphrodism) ;  but  no 
authentic  case  is  known  of  this  kind.  Klebs  thinks  that  perhaps 
Bannon's  case  belongs  to  this  group,  but  it  appears  from  his  abstract 
that  he  has  not  seen  the  original,  since  he  is  entirely  misinformed 
in  regard  to  many  important  points.  The  individual  died  at  the 
age  of  twenty-six  years,  and  was  supposed  to  be  a  man.  The  exter- 
nal genitals  w^ere  of  an  undecided  character.  There  was  a  hymen,  a 
vagina,  and  a  uterus,  from  the  left  upper  angle  of  which  started  a 
Fallopian  tube,  but  it  went  between  the  uterus  and  rectum  over  to 
the  right  side  to  a  body  which  is  called  an  ovarv'.  On  the  same  side 
was  found  a  testicle  with  epididymis,  from  which  a  long  tube,  which 
Bannon  takes  to  be  a  vas  deferens,  went  to  the  right  upper  angle  of  the 
uterus  and  communicated  Avith  its  cavity.  I  therefore  take  it  rather  to 
be  an  elongated  Fallopian  tube.  Behind  and  partly  in  the  internal 
inguinal  ring  was  found  "  a  glandular  organ."  Xo  description  is  given 
of  the  latter,  nor  does  it  seem  to  have  been  examined  microscopically. 
The  supposed  ovary  was  submitted  to  such  an  examination,  and  a 
drawing  is  given  of  its  appearance  ;  but  no  description  except  the  words 
"  the  granules  visible  are  not  Graafian  follicles,  but  appeared  to  be  fat- 
globules  ;"  and  the  drawing  has  not  the  slightest  resemblance  to  the 
structure  of  an  ovary.  The  testicle  had  an  albuginea  and  the  tubular 
arrangement  proper  to  that  organ.  The  fluid  contained  in  the  com- 
mencement of  the  vas  deferens  and  epididymis  had  the  peculiar  odor 
and  consistence  of  the  human  semen.  Under  the  microscope  it  showed 
numerous  cells  containing  granules,  but  no  trace  of  spermatozoids.  It 
is  clear  that  it  was  only,  so  to  say,  accidental  that  the  left  genital  gland 


270  MALFORMATIONS   OF  THE  FEMALE  GENITALS. 

was  found  on  the  right  side,  and  no  genital  character  is  claimed  for  the 
"  glandular  organ  "  at  the  entrance  of  the  inguinal  canal ;  and  while  it 
must  be  admitted  that  the  individual  had  a  testis,  it  is  not  proved,  and 
not  even  made  likely,  that  he  had  an  ovary.  But  if  Heppuer's  case  is 
admitted  as  one  of  true  bilateral  hermaphrodism,  we  may  of  course  as 
well  expect  once  to  find  a  similar  case  with  a  double  sexual  gland  on 
one  side  and  a  single  on  the  other. 

It  is  difficult  yet  not  impossible  to  understand  how  the  same  indi- 
vidual can  have  more  than  one  set  of  reproductive  glands,  for  we  have 
seen  (p.  76)  that  it  is  one  and  the  same  body,  which,  identical  in  the 
beginning,  later  turns  out  to  be  either  a  testicle  or  an  ovary.  The 
connective  tissue  that  goes  to  form  the  ovary  or  the  testicle  is  indeed 
identically  the  same  substance ;  but  perhaps  the  epithelial  part  of  the 
two  glands  has  a  different  origin.  Wakleyer  thinks,  namely,  that  the 
seminal  canals  are  formed  as  invaginations  from  the  Wolffian  duct, 
while  the  follicles  in  the  ovaries  are  derived  from  the  germ-epithe- 
lium. 

We  have  furthermore  seen  (p.  92)  that  supernumerary  ovaries  may 
be  found,  and  that  not  only  by  a  division  of  one  larger  body,  but  as  a 
separate  body  of  the  size  of  a  normal  testicle.  As  to  testicles,  there 
is  only  one  case  on  record  of  three  testicles  being  found  in  the  same 
individual  at  an  autopsy,  and  even  this  case  is  not  beyond  dispute. 
The  other  cases  regard  living  men,  and  are  consequently  still  less  con- 
vincing (Foerster).  If  thus  we  can  have  more  than  two  glands  of  the 
same  sex,  the  possibility  of  one  or  more  of  them  having  the  type  cha- 
racteristic of  the  other  sex  is  given. 

It  must  be  admitted  that  at  the  very  earliest  point  of  develop- 
ment every  human  individual  is,  in  a  certain  sense,  hermaphroditic, 
inasmuch  as  there  is  a  common  foundation  for  the  urogenital  system, 
which  very  soon  separates  into  two  parts,  the  germ-epithelium  and  the 
epithelium  of  the  AVolffian  duct,  the  first  of  which  is  developed  to  the 
female  sexual  glands  and  ducts,  while  the  second  forms  the  male  ducts, 
the  uropoetic  system,  and  probably  the  male  glands.  Even  in  female 
individuals  the  beginning  of  seminal  canals  are  found  in  the  parova- 
rium, and,  on  the  other  hand,  sometimes  some  large  cells  are  found  in 
the  surface  epithelium  of  the  testicle  which  are  supposed  to  be  primor- 
dial ova. 

The  third  possibility  of  true  hermaphrodism  is  the  presence  of  a  tes- 
ticle on  one  side  and  an  ovary  on  the  other  {true  lateral  hermaphrodism). 
From  what  we  have  just  said  about  the  identity  of  the  two  glands,  it  is 
not  unlikely  that  one  might  be  developed  according  to  the  male  and  the 
other  to  the  female  type. 

The  most  important  case  of  supposed  true  lateral  hermaphrodism  is 
a  specimen  found  in  the  pathological  museum  at  Ziirich.     It  comes 


HKRMM'lUtnDISM. 


271 


Fig.  1(i-J. 


iVoiii  11  newhorn  child,  aii<l  was  first  dt'scrilMMl  hy  II.  Meyer,  and  later 
examined  mierosenpicaily  and  do.s<'ril)e<l  In'  ]vl«'i)s.  (For  details  wc 
nui.-t  refer  tlie  reader  to  the  work  of  tlu;  latter,  luc.  rit.,  \t.  728  ;  here  we 
must  limit  oui'selves  to  the  most  important 
features  of  the  ea.so.)  The  child  had  a  slntit 
j)enis  with  a  lar«;e  glans  anil  a  bulky  pre- 
puce (Fii;.  102).  On  the  end  of  the  ^lans 
is  a  l)liud  ui-ethra.  lielow,  the  prepuce  is 
continued  in  a  fissui'e,  the  posterior  jjart  of 
which  leads  into  the  sinus  uro»i;enitali.s.  Be- 
hind this  openinjji;  is  a  raphe  uniting  the  two 
hal\es  of  a  well-tie veloped  scrotum,  in  the 
left  half  of  whieh  is  found  a  testicle.  From 
the  sides  of  the  fjenital  fissure,  near  the  en- 
trance to  the  sinus  urogenitalis,  start  two  low 

ridw;es  of  skin  which  run  backward  and  out-  External  Genitals  in  a  case  of  her- 

1  ^      ^i  i      f>  ^1  •  /-v      ,1  maphrodismus  lateralis:  a,  scro- 

ward  to  the    root  Ot    the  penis.       On  the  pos-      tmn;  6,  labia  majora;c,  prepuce; 

terior  wall  of  the  sinus    Urogenitalis  is  found      '^'  ^^^'^^  minora:  e,  entrance  to 
•      T         .1  1    />  sinus  urogenitalis.  (From  Klebs.) 

a  colliculus  semnialis  with  several  fine  aper- 
tures, none  of  which  lead  to  a  vas  deferens,  but  one,  on  the  left  side, 
leads  into  a  vagina  and  uterus  arcuatus  (Fig.  103).     A  slight  swelling 
round  the  genital  canal  at  the  seat  of  the  colliculus  seminalis  shows  the 
micEoscopicaL  structure  of  the  prostate.     From  the  right  horn  of  the 

Fig.  103. 


Intemal  Genitals  of  the  same  case  of  lateral  hermaphrodism,  seen  from  behind  :  a,  bladder ; 
6,6,  ureters ;  c,  vaginal  entrance  :  c,  d,  vagina  ;  d,  external  os ;  e,  e,  Fallopian  tubes ;  /,  ovar>-: 
p,  parovarium  ;  A,  right  Morgagni's  hydatid  ;  t,  testicle  ;  it,  ovarian  (or  testicular)  ligament ; 
/,  epididymis;  in,  bundle  of  vessels  and  nerves  of  the  cord;  n,  vasa  deferentia;  o,  o,  hyda- 
tids of  left  tube;  p,  peritoneal  pouch  in  left  half  of  scrotum,  containing  <■/,  left  round  iiga- 
ment,  and  >-,  guberuaculum  Humeri ;  r,  right  round  ligament;  P.  prostate.   (From  Klebs.) 

uterus  .start  the  round  ligament,  the  ovarian  ligament  leading  to  a  club- 
shapetl  body  supposed  to  be  an  ovaiy,  and  finally  the  Fallopian  tube. 
Between  the  ovary  and  the  tube  is  found  a  parovarium.  The  micro- 
scopical examination  of  the  supposed  ovaiy  shows  total  abtsencc  of  J'ol- 


272 


MALFORMATIONS  OF  THE  FEMALE  GENITALS. 


licles,  with  which  the  normal  ovaries  of  newborn  children  are  crowded. 
The  stroma  is  composed  of  a  dense  fibrous  tissue  with  many  nuclei,  as 
in  the  rete  vasculosum  testis,  and  tunnelled  by  numerous  branching  and 
anastomosing  canals  from  8  to  20  micromillimeters  ^  in  width.  They 
have  no  proper  wall,  but  the  surrounding  tissue  forms  a  fine  double 
contour.  Their  interior  is  filled  with  small  polygonal  cells  measuring 
from  3  to  5  micromillimeters  in  diameter,  and  showing  a  nucleus  and 
a  granular  protoplasm.  Besides  these  small  cells  are  in  the  larger 
canals  found  straggling  larger  cells  measuring  11.4  by  7  micromilli- 
meters, and  distinguished  from  the  others  by  their  brightness.  Klebs 
takes  them  to  be  primordial  ova.  Furthermore,  he  found  in  the  few 
sections  he  made  from  the  rare  specimen  a  large  round  cavity  measur- 
ing 80  by  64  micromillimeters,  and  surrounded  by  concentric  fibres  of 
connective  tissue.  It  contained  a  fine  granular  mass  and  several  nuclei 
measuring  5  by  7  micromillimeters.  Although  no  ovum  was  found  in 
this  cavity,  Klebs  looks  upon  it  as  a  follicle. 

On  the  left  side  (Fig.  104  will  give  a  clearer  idea  of  the  organs  on  this 
side)  the  round  ligament  descends  into  the  open  peritoneal  pouch  con- 
taining the  testicle,  and  spreads  out 
^^^-  ^^^-  on  the  walls  of  the  sac.    At  the  end 

of  the  ovarian  ligament  (j),  which 
here  must  be  called  a  testicular  lig- 
ament, is  found  an  oval  body  which 
both  macroscopically  and  micro- 
scopically answers  to  a  testis.  At 
the  upper  end  of  the  testis  (^4)  is 
found  a  coniform  protuberans  {B), 
which  microscopically  shows  the 
texture  of  the  rete  testis.  Inside 
of  this  body  is  found  a  bundle  of 
blood-vessels  and  nerves  (P)  corresponding  to  the  spermatic  cord,  but 
without  any  vas  deferens.  Between  this  bundle  and  the  above-men- 
tioned ligament  is  seen  another  ligament  going  from  the  testicle  to  the 
bottom  of  tlie  pouch  in  which  the  testicle  is  enclosed.  This  ligament 
represents  the  gubernaculum  testis  {h).  Above  the  rete  testis  is  found 
the  epididymis,  the  head  (C)  forming  a  right  angle  with  the  tail  (Z)). 
From  the  tail  start  the  vas  aberrans  Halleri  {e)  and  some  blood-vessels 
going  to  the  above-mentioned  bundle  representing  the  spermatic  cord. 
Finally,  above  the  epididymis  is  seen  the  tube  {K)  with  fimbriae  (X)  and 
two  small  pedunculated  cysts,  the  one  {m)  starting  from  the  fimbria 
ovarica,  and  the  other  (N)  connected  by  means  of  a  peritoneal  fold  with 
the  head  of  the  epididymis,  the  hydatid  of  which  it  probably  is. 

I  have  given  all  these  details  because  this  is  the  best  examined  of  all 
^  A  micromillimeter,  the  sign  for  which  is  //,  is  one-thousandth  of  a  millimeter. 


ITERMAI'linoi)Is.}f.  273 

<US(><,  l)Mt  1  (111  not  ;ii:rcc  with  KIrhs  ill  liis  cDiicliisidii  tli:it  the  K-xiial 
t:;l;iiitl  on  tlic  i"i<;lit  side  is  ;iii  ovarv — :i  coiicliisioii  wliiih  is  \v;irr:iiitc<l 
iicitlicr  1)V  tlu'  cxtcninl  nppcaraiK-c  nor  l»y  tlic  striK-tiirc  of"  tlic  IxmIv. 
()ii  lilt'  »'()iiti-arv,  it  scciiis  to  iiw  that  the  (U'scriptioii  nf  tlic  liistolof^ical 
(Miiii|)nsiti(»n  rciiiiiids  iiuicli  nioir  of  a  testicle  than  of"  an  ovarv. 

There  is  another  ease  of  threat  interest  which  j)crha[)s  is  one  of  true 
hit<'ral  hcrniaj)hrodism.  It  has  the  advantage  over  the  former  of  Ix-ing 
that  of  an  a<hdt,  bnt  the  disadvantajre  that  the  person  in  (|nestion  is 
still  livin*;,  and  that  conse(|iicntly  the  nature  of  the  internal  parts  is 
subjected  to  doubt.  Wi'  refer  to  the  famous  Catharine  or  Carl  Hoh- 
nianu.'  This  individual  has  been  most  carefully  examined  by  such 
competent  observers  as  O,  von  Francpie,  Rokitansky,  X.  Friedreich, 
S.  B.  Schultze,  and  P.  F.  Munde.  We  will  use  the  masculine  i)ro- 
noun  in  speakino;  of  this  person,  since  his  male  nature  is  proved  beyond 
a  doubt,  while  the  female  is  still  sab  judice.  He  was  born  in  Bavaria 
in  1.S24,  and  spent  the  first  forty-six  years  of  his  existence  as  a  female. 
In  his  twelfth  year  the  genitals  and  breasts  increased  in  size,  and  soon 
afterward  he  Ijegan  to  feel  sexual  propensities,  which  at  that  time  were 
entirely  directed  toward  the  male  sex.  At  the  age  of  seventeen  he  took 
unto  himself  a  male  lover,  with  whom  he  cohabited  for  twenty  years. 
The  attempts  at  coition  were  accompanied  by  the  discharge  of  a  thin 
viscid  fluid  from  the  urethra,  the  emission  of  which  coincided  with  the 
org.ism  and  wiis  not  attended  by  any  erection  of  the  clitoris.  Las- 
civious thoughts  would  be  followed  by  this  same  emission,  and  sexual 
excitement  always  brought  on  a  peculiar  thrill  or  glow  on  the  left;  side 
of  the  pelvis.  In  his  nineteenth  year  a  discharge  of  blood  took  place 
from  the  urethra,  which  for  some  time  returned  at  irregular  inter- 
vals and  finally  reappeared  every  tliree  or  four  weeks,  lasting  from 
three  to  six  days.  This  regular  Ijloody  discharge  was  preceded  by 
tumefaction  of  the  breasts,  easy  erectibility  of  the  nipples,  and  the 
secretion  of  a  colostrum-like  fluid,  which  could  be  pressed  out  from 
the  latter.  This  secretion  disappeared  again  when  he  was  about  forty 
years  old,  and  in  his  forty-third  year  the  bloody  discharge  stopped. 
This  periodical  bloody  discharge  has  been  repeatedly  watched  and  the 
fluid  examined  microscopically,  so  as  to  exclude  every  fraud.  It  M'as 
composed  of  mucus  with  fresh  human  blood-corpuscles  exactly  like 
menstrual  blood.  In  his  twenty-fifth  or  twenty-sixth  year  beard-hairs 
a})peared,  which  he  tore  out. 

In  1870  he  made  his  first  attempt  at  sexual  intercourse  as  a  man, 
and  from  that  time  he  had  nocturnal  emissions  of  a  fluid,  the  seminal 
nature  of  which  has  been  proved  with  absolute  certainty.  It  lookeil  and 
smelt  like  semen,  and  on  microscopical  examination  it  Avas  found  to 
abound  in  Avell-shaped  spermatozoids  in  lively  movement. 

'  The  name  is  sometimes  spelt  Homann  (Rokitansky)  or  Humann  (Von  Franqu^). 
Vol.  I. — IS 


274  MALFORMATIONS  OF  THE  FEMALE  GENITALS. 


Fig.  105.— Penis  aud  Scrotum,  side  view. 


Fig. 106. 


Fig.  lOe.-Same,  more  from  the  front,  a  stylet  introduced  into  the  opening  of  the  urethra. 


IIERMA  PIIRODISM. 


275 


Frri.  107 


Fi<;  108. 


Fig.  107.— Upper  Half  of  Anterior  Surface,  show- 
ing the  breasts. 


Fig.  108.— Posterior  Surface,  showing  the 
long  hair,  the  slender  back,  the  bKoad 
hips,  and  the  finer  build  of  the  left  side. 


Fig.   110. 


Fig.  109. 


Fic.  110.— A  supposed  transverse  section 
through  the  pelvis:  P.  promontory;  h, 
urethra ;  m,  uterus ;  k,  sexual  gland.  Be- 
tween u  and  k  is  seen  the  Fallopian  tube. 


Rectum 


Fig.  109.— a  supposed  sagittal  section  :  a,  meatus ;  v,  entrance  to  vagina ;  w,  uterus. 


276  MALFORMATIONS   OF  THE  FEMALE  GENITALS. 

Here,  then,  we  have  a  human  being  uniting  the  production  of  semen 
with  a  periodical  discharge  of  blood  mixed  with  mucus  from  the  geni- 
tals. Still,  it  would  be  risky  to  conclude  from  these  premises  that  the 
individual  has  double  sex  in  the  strict  sense  of  the  word.  While  the 
presence  of  a  testicle  is  proved,  that  of  an  ovary  is  yet  doubtful.  The 
presence  of  a  periodical  bloody  discharge  from  the  genitals  is  not  con- 
clusive, since  a  similar  condition  has  been  found  combined  with  normal 
male  genitals  (Rayer),  and  especially  in  males  suifering  from  h^^^ospa- 
dias  (Th.  Allen,  Morand). 

Carl  Hohmann  has  later  donned  manly  attire,  has  had  his  hair  cut 
short,  and  is  married  to  a  woman.  Formerly  he  used  to  have  wavy, 
black  hair,  descending  to  the  waist,  as  seen  in  Fig.  108.  The  left  side 
of  the  face  has  a  feminine  type,  and  the  whole  left  side  of  the  body  is 
less  strongly  developed  than  the  right.  The  beard  is  slight,  but  dis- 
tinct. He  has  large,  well-formed  breasts,  with  large  areolae  and  large, 
prominent .  nipples.  The  larynx  is  large,  with  prominent  pomum 
Adami,  and  the  voice  is  deep  and  full,  but  Hohmann  says  he  sings 
soprano.  The  back  has  a  female  curve.  The  pelvis  approaches  the 
male  type,  but  seems  to  be  more  capacious  than  in  the  normal  male. 
The  hips  are  broad  and  the  knees  converge  as  in  a  woman. 

The  external  genitals  present  a  masculine  appearance.  He  has  a 
penis,  bound  as  far  as  the  glans  to  the  subjacent  integument.  It  is  two 
and  a  half  inches  long,'  but  during  turgescence  it  measures  five  and  a 
half  inches.  At  the  end  is  a  blind  longitudinal  furrow.  The  urethra 
'opens  on  the  posterior  aspect  of  the  glans  near  the  corona,  and  admits 
easily  a  sound  measuring  twenty-four  millimeters  in  circumference, 
which  passes  without  resistance  into  the  bladder.  Below  the  urethral 
aperture  is  a  shallow  recess  covered  with  integument,  but  no  trace  of  a 
vagina.  On  the  right  side  there  is  a  well-developed  scrotum  and  testicle, 
with  epididymis  and  vas  deferens.  The  left  half  of  the  scrotum  is 
shorter,  thinner,  and  more  like  a  labium  majus.  At  the  bottom  was 
formerly  found  a  hard  mass  without  distinct  limits,  which  even  then 
was  looked  upon  as  connective  and  adipose  tissue,  and  which  now  has 
disappeared.  In  the  left  groin  is  found  a  body  of  the  size  of  a  bean, 
the  nature  of  which  cannot  l^e  ascertained,  but  which  some  observers 
take  to  be  an  atrophic  testicle,  while  others  think  it  is  the  empty  sac 
of  a  crural  hernia. 

From  the  apex  of  the  penis  two  tortuous  folds  of  skin  run  upward 
to  the  mons  Veneris.  It  has  been  surmised  that  they  might  represent 
labia  minora.  In  the  preceding  case  somewhat  similar  folds  Avere  found, 
but  there  they  started  from  a  lower  point — namely,  from  the  posterior 
end  of  the  long  cleft  frsenulum,  from  Avhich  point  they  ran  over  the 

1  This  is  taken  from  Yon  Franque's  dravring.  Friedreich  says  three  inches,  and 
Munde  one  and  a  half. 


ni'.nMM'unoinsM.  -iii 

scrotum  to  the  root  of  the  penis  {V"\\!^.  1(>2).  Klclis  statts  {loc.  cH.,  ji. 
7.">.">)  tli;it  Bi'cisky  li;is  found  similar  folds  in  otherwise;  entirely  n<ti- 
mnl  women  rnmiin<;-  from  the  postei'ior  commissure  to  the  imier  siu'facc! 
of  the  lahia   majora. 

As  to  the  conditi<»n  of  the  internal  jicnitals,  a  medium-sized  male 
catheter  can  ho  introduced  thron<2;h  the  urethra  into  a  female  <;<'nital 
canal,  which  deviates  somewhat  to  the  left  and  terminates  in  a  button- 
shaped  expansion  (Fi}2;.  109,  u),  the  fundus  uteri,  from  wiiich  a  cord, 
taUen  to  he  a  Fallopian  tube,  goes  off  to  the  left  side  of  the  pelvis, 
where  it  terminates  in  a  somewhat  movable  cylindrical  body  several 
cubic  centimeters  larcro,  which  is  sensitive  to  the  touch,  and  probably  is 
the  left  sexual  oland ;  but  wlicther  it  is  a  testicle  or  an  ovary  can  only 
be  settled  by  a  future  post-mortem  examination.  Thus  this  case  as 
little  as  any  other  can  be  said  to  be  positively  jiroved  to  be  one  of 
true  herma[)hrodism.  (Figs.  106-110,  illustrating  the  description, 
are  taken  from  the  American  Journal  of  Obstetrics,  1875,  vol.  viii, 
p.  615.) 

Spurious  Hermaphrodism  (Hermaphrodisnius  spurius,  s.  Pseudo- 
hermaphrodismus). — By  spurious  hermaphrodism  is  meant  the  condition 
in  which  the  sexual  glands  belong  to  one  sex,  either  masculine  or  femi- 
nine, and  the  passages  leading  from  them,  as  well  as  the  external  parts, 
more  or  less  approach  those  of  the  other.  Spurious  hermaphrodism 
is  subdivided  according  to  the  nature  of  the  sexual  glands  into  mals 
psendo-liermaphrodmii  and/(?»i«7e  pseudo-hcrmapjhrodmn,  each  of  which 
comprises  three  groups,  the  first  being  formed  by  those  cases  in  which 
the  ducts  alone  belong  to  the  opposite  sex  {internal  male  or  female  pseit- 
do-hcrmaphrodisrn) ;  the  second,  by  those  in  which  the  external  parts 
alone  represent  the  opposite  sex  (external  male  or  female  pseudo-her- 
maphrodiftm) ;  the  third,  those  in  which  both  the  ducts  and  the  exter- 
nal parts  a})proach  those  normally  found  in  the  other  sex  (internal  and 
external  complete  male  or  female  pseudo-hermaphrodism). 

Slight  aberrations,  such  as  atresia  of  the  vulva  in  the  female  or  hypo- 
spadias and  slight  enlargement  of  the  prostatic  vesicle  in  the  male,  due 
to  local  disturbances  during  foetal  development,  are  not  counted  as  con- 
stituting hermaphrodism,  but  it  may  of  course  become  difficult  to  draw 
the  line. 

Pseudo-hermaphrodism,  as  well  as  true  hermaphrodism,  dates  from 
the  earliest  periods  of  foetal  development.  It  is  much  more  common 
in  the  male  than  in  the  female  sex,  and  it  reaches  likewise  its  greatest 
development  in  the  former  sex ;  so  that  the  vagina,  uterus,  and  tubes 
may  be  found  more  or  less  complet-ely  developed  in  an  individual  with 
testicles,  vasa  deferentia,  seminal  vesicles,  and  male  external  genitals. 

The  external  genitals  being  formed  of  the  same  substance  in  the  two 
sexes,  it  is  not  possible  to  have  a  double  set  of  them,  one  male,  the  other 


278  MALFORMATIONS  OF  THE  FEMALE  GENITALS. 

female ;  but  some  parts  assume  more  of  the  one  type,  and  others  more 
of  the  other. 

The  general  appearance  of  the  body,  especially  in  regard  to  the 
growth  of  hair,  the  development  of  the  breasts,  the  prominence  of  the 
pomum  Adami,  the  breadth  of  the  hips,  and  the  angularity  or  round- 
ness of  the  contour  of  the  body,  presents  commonly  a  mixture  of  both 
sexes,  the  preponderance  being  in  conformity  not  with  the  real  sex  as 
determined  by  the  sexual  glands,  but  with  the  external  genitals.  Thus, 
a  female  with  ovaries  and  male  external  genitals  will,  as  a  rule,  be  more 
like  a  man  as  to  build,  and  a  male  with  testicles  and  female  external 
genitals  commonly  looks  more  like  a  female. 

Literature  Referred  to} 

Ahlfeld,  F.  :  Di'e  Missbildungen  des  Menschen,  Leipzig,  1880. 

:  "  Ueber  einen  Monopus  mit  vollstandigem  Mangel  der  aeusseren  Genitalien 

und  des  Afters"  {Arch.f.  GyndL,  1879,  vol.  xiv.  p.  276). 
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V.  p.  380,  frona  Glasgow  Med.  Journ.,  May,  1872). 
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{Am.  Journ.  Obst.,  1883,  vol.  xvi.  p.  180). 
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14,  1860,  vol.  i.  p.  45). 
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1878). 
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xxvii.  p.  66). 
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vol.  XXV.  p.  99). 

:  "Spurious  Hermaphroditism"  {Land.  Obst.  Trans.,  1882,  vol.  xxiv.  p.  188). 

Barnes,  R.  :  "On  Hernia  of  the  Ovary"  {Am.  Journ.  Obst.,  1883,  vol.  xvi.  p.  1). 
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42,  43. 

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■  Ovariums  links"  {Arch.f.  Gyndk.,  1877,  vol.  xi.  p.  380). 
BoRiNSKY,  S. :  "  Daseine  Horn  eines  Uterus  duplex  als  irreponibles  Hinderniss  fiir 

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X.  p.  145). 
Breisky,  a.:  "Hydrometra  lateralis"  {Arch. fiir  Gyndk.,  1874,  vol.  vi.  p.  89). 

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:  "  Ein  neuer  Fall  von  Pyometra  und  Pyokolpos  lateralis  "  {Arch,  fur   Gyndk., 

1871,  vol.  ii.  p.  451). 
Brown,  W.  S. :  "Atresia  Vaginse"  {Am.  Journ.  Obst.,  1880,  vol.  xiii.  p.  192). 
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251). 
Chalmers:  "Hermaphrodite"  {Lond.  Obst.  Trans.,  1882,  vol.  xxiv.  p.  239). 
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162). 
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1879,  vol.  xxi.  p.  256). 

1  Works  mentioned  in  the  preceding  article  ("  Tlie  Development  of  the  Female  Genitals  ") 
are  not  repeated. 


i.iTi:iL\Trni':.  279 

ClkvELAND,   W.    1".:   ••  liH.ini    nf  I  Niul.tliil   Si-x  "   {I,<,„<l.   (JIjhI.    Tinm.,   18G8,  vol.   ix. 

p.  29). 
CoKN  :  "A  Ca.SL'  of  Alxsenco  of  Uterus  and  V'liKiiui,  and  other  Malformations"  ffrorn 

Annali  Univvrmli  <lf  Mnl.,  Jan.,  1HS4,  in  fnitnilU./.  (lijiuil:.,  IH.Sl,  vol.  viii.  p.  714). 
Coi'KMAN,  E. :   "On  tlio  Tri-alrncnt  of  Impfrfoniti;  llyim-ii  "  (  Litml.  ObxI.  'J'rnnx.,  IWJ, 

vol.  X.  p.  24G). 
('roS!«,  E.  :  "A  Case  of  Oeeliision  of  the  N'agiiia  complieated  by   Prejjnaney  "   (.4m. 

Journ.  ObsL,  1883,  vol.  xvi.  (..  HO'.)). 
Da  V I  li*,  G. :  "Abdominal   ( 'ysl   in  a   Newiy-liorn  Chiiil"   t  Loml.  OImI.  Tramt.,  ]H~~  , 

vol.  xix.  p.  5). 
Davis,  E.  H.  :  "Case  of  Atresia  of  tiie  Vagina"  {Am.  Jnurn.   Ohd.,   1872,  vol.  v.  p. 

396). 
Dk  Forest,  W.  :  "Case  of  Spurious  Ik'rmaphrodisra  "  {Aui.  Journ.  Obnt.,  187G,  vol. 

ix.  p.  500). 
DiKNKR,  G.  A.:  "Ein  Fall  von  doppelter  Gebiirmutter  raitdoppelter  Scheide  (Uterus 

didelphys  c.  vagina  dnplice)"  {Arch.f.  Gyndk ,  1883,  vol.  xxii.  p.  463). 
Don  UN,  K.:  "Die    Bildunjrsfehler  des   Hymens"   {Zeitschr.  f.  Geburlshulje  u.  Gynd- 

koloyie,  1884,  vol.  xi.  p.  1 ). 

:  "Ein  Fall  von  Atresia  vaginalis"  (ArrJi./iir  Gyndk.,  1877,  vol.  x.  p.  544). 

:  "Ein  verheiratheter  Zwitter"  {Arch. far  Gynak.,  1877,  vol.  xi.  p.  208). 

:  "Ein  verheiratheter  Zwitter"  {Archivfur  Gyndk.,  1884,  vol.  xxii.  p.  225). 

DouAN,  A.:  "Deficient  Development  of  the  Uterus  (Ulermfcetalii),  Atresia  of  the  Os 

Externum,  Atropliy  of  the  Ovaries,  Insanity"  {Loud.  Obst.  Trans.,  1879,  vol.  xxi. 

p.  253). 
:    "  Dissection  of  the   Genito-urinary   Organs   in   a   Case   of  Fissure   of  the 

Abdominal  Walls"  (Joarn.  Anal,  and  Physiol.,  1881,  vol.  xv.  p.  226). 
:  "Congenital    Communication  between  the  Rectum  and  the  Genito-urinarv 


Tract"  {Lond.  Obst.  Trans.,  1880,  vol.  xxii.  p.  79). 
Duncan,  M.  :  "Case  of  So-called  Imperforate  Hymen"   (Lond.  Obst.  Trans.,  1882, 

vol.  xxiv.  p.  212). 
:  "  Delivery  in  a  Case  of  Double  Uterus"  {Lond.  Obst.  Trans.,  1881,  vol.  xxiii. 

p.  21). 

'  Pyometra  "  {Land.  Obst.  Trans.,  1879,  vol.  xxi.  p.  54). 


Em.met,  T.  a.:  "A  Case  of  Hermaphrodism  "  {Am.  .Town.  Obst.,  1881,  vol.  xiv.  p. 

882). 
:  "  Congenital  Absence  and  Accidental    Atresia  of  the  Vagina "  {Am.  Gyn. 

Tran-i.,  1877,  vol.  ii.  p.  437). 
FoERSTER,  A.:  Handbuch  der  Pathologischai  Anatomie,  2te  Aufl.,  Leipzig,  1863.  • 

Fort,  C.  H. :  "Some  Corroborative  Facts  in  Regard  to  the  Anatomical  Difference 

between  the  Negro  and  White  Races"  (Am.  Journ.  Obst.,  1877,  vol.  x.  p.  258). 
Franque,  O.  von:   "  Beitrag  zur  Lehre  (iber  den  Herraaphroditismus  lateralis" 

{Scanzoni^s  Beiirdge  zur  Geburtshulfe  nnd  Gyndkologie,  vol.  v.  p.  57,  Wiirzburg,  1869). 
Freund,  Wm.  a.  :  "Horseshoe  Kidney,  with  Absence  of  Internal  Organs  of  Genera- 
tion" (.4m.  Journ.  Obst.,  1876,  vol.  ix.  p.  349,  from  Berl.  Beitr.  z.  Geb.  u.  Gyn.,  iv.  i.). 
Friedreich,  N. :  "Der  Hermaphrodit  Catharina  Honiann"  {Virchoiu's  A  rchiv,  vol. 

xlv.  pp.  1-8). 
Galabix,  a.  L.  :  "Retention  of  Menstrual  Fluid  in  one  half  of  a  Double  Uterus" 

(Land.  Obst.  Trans.,  1882,  vol.  xxiv.  p.  21). 
Garrigues,  H.  J. :  "  The  Obstetrical  Treatment  of  the  Perineum  "  (Am.  Journ.  Obst., 

April,  1880,  vol.  xiii.  p.  231). 
Gervis,  H. :  "Case  of  Transverse  Septum  in  the  Vagina"  {Lond.  Obst.  Trans.,  1882, 

vol.  xxiv.  p.  210). 
:  Case  of  Double  Vagina  and  Uterus"  {Lond.  Obst.  Trans.,  1877,  vol.  xix.  p. 

271). 


280  MALFORMATIONS   OF  THE  FEMALE  GENITALS. 

Gkace,  H.  :  "Case  of  Double  Uterus,  with  Simultaneous   Gestation"   {Lond.   Obst. 

Trans.,  1863,  vol.  iv.  p.  138). 
Hegar,  a.  :  Die  Castration  der  Frauen,  Leipzig,  1878. 
Heppner,  C.  L.  :  "Ueber  den  wahren  Hermaphroditismus  heim  Menschen"  {Reich- 

ert's  Archiv,  1870,  p.  679). 
Hicks,  J.  B. :  "An  Unilateral  Uterus  and  Kidney,  with  Two  Ureters"  {Lond.  Obst. 

Trans.,  1879,  vol.  xxi.  p.  57). 
:  "  Case  of  Congenital  Abnormality  of  the  Uterus   simulating  Ketention  of 

Menses"  {Lond.  Obst.  Trans.,  1880,  vol.  xxii.  p.  260). 

:  "Five  Cases  of  Vaginal  Closure"  {Lond.  Obst.  Trans.,  1863,  vol.  iv.  p.  228). 

:  "Case  of  Pregnancy  with  Double  Uterus  and  Vagina"  {Lond.  Obst.  Trans., 

1881,  vol.  xxiii,  p.  23). 
:  "Vertical  Septum  in  Lower  Part  of  Vagina,  impeding  Labor"  {Lond.  Obst. 

Trans.,  1881,  vol.  xxiii.  p.  24). 
:  "  Absence  of  Uterus  and  Ovaries :  on  the  top  of  the  vagina  a  large  cyst  half 

filled  with  a  cheesy  white  matter,  and  the  rest  with  dark  grumous  material  like  old 

clots"  {Lond.  Obst.  Trans.,  1880,  vol.  xxii.  p.  262). 
HiLDEBRANDT,  H. :  "Die  Krankheiten  der  Aeusseren  Weiblichen  Genitalien"  {Bill- 
roth's  Frauenkrankheiien,  vol.  iii.,  part  vii.,  Stuttgart,  1877). 
HowiTZ,  F.:   "Laparotomi  for  Pyometra  i  hojre  Uterushorn"  {Howitz's  Gyncek.  og 

Obst.  Meddelelser,  1881,  vol.  iii.  p.  70). 
Hyatt,  H.  O.  :  "  Note  on  the  Normal  Anatomy  of  the  Vulvo-vaginal  Orifice  "  {Amer. 

Journ.  Obsiet.,  1877,  vol.  x.  p.  253). 
Jackson,  A.  K. :  "A  Contribution  to  the  Relations  of  Ovulation  and  Menstruation" 

{Journ.  Am.  Med.  Assoc.,  Chicago,  1884). 
JoHANNOVSKY,  V. :  "  Einige  Bildungsfehler  der  Weiblichen  Genitalien  aus  der  Gyna- 

kologischen  Klinik  des  Prof.  Breisky  in  Prag"  {Arch.  f.  Gyndk.,  1877,  vol.  xi.  p. 

371). 
Kaltenbach  :    "  Demonstration   eines   Uterus  unicornis  mit  geplatztem   gravidem 

Nebenhorn"  {Arch.  f.  Gyndk.,  1883,  vol.  xxii.  p.  172). 
Klebs,  E.  :  Handbuch  der  Pathologischen  Anatomic,  Berlin,  1876. 
Klob,  J.  M. :  Pathologische  Anatomic  der  Weiblichen  Sexualorgane,  Wien,  1864. 
KussMAXJL,  A. :  Von  dcm  Mangel,  der  Verkiimmerung  und  Verdopplwng  der  Gebdrmidter, 

Wiirzburg,  1859. 
Lebedeff,  a.:  "Ueber  Hypospadie  beim  Weibe"  {Arch.  f.  Gyndk.,  1880,  vol.  xvi. 

p.  290). 
Le  Fort,  L.  :  Des  Vices  de  Conformation  de  I'  Uterus  et  du  Vagin,  et  des  Mayens  d'y 

licmedier,  Paris,  1863. 
Lente,  F.  D.  :  "Operation  for  Atresia  Vaginse"  {Ain.  Journ.  Obstet.,  1877,  vol.  x. 

p.  85). 
Leopold,  G.  :  "  Ein  mannlicher  Scheinzwitter,  Pseudo-hermaphrodismus  externus  "  ^ 

{Arch.  f.  Gyndk.,  1876,  vol.  viii.  p.  487). 
:  "Ueber  eine  vollstandige  mannliche  Zwitterbildung"  {Arch.  f.  Gyndk.,  1877, 

vol.  xi.  p.  357). 
Madge,  H.  M.  :  "  Four  Cases  of  Congenital  Imperforate  Vagina,  and  one  Case  of  Con- 
genital Phymosis,  occurring  in  the  Same  Family"  {Lond.  Obst.  Trans.,  1870,  vol.  xi. 

p.  213). 
Mann,  M.  D.  :    "A  Specimen  of  an  Infant  Uterus  Bicornis  Duplex  and  Vagina 

Septa"  {Am.  Journ.  Obst.,  1874,  vol.  vii.  p.  274). 
— :   "  Case  of  Uterus  Bicornis,  with  a  Partial  Vaginal   Septum  "    {Am.  Journ. 

Obst,  1877,  vol.  X.  p.  666). 

»  Since  there  was  a  vagina  eight  centimeters  long,  I  think  this  ought  rather  to  be  regarded  as 
a  case  of  pseudo-hermaphrodismns  masculinus  internus  and  externus  ;  so  much  more  so  as  the 
examination  was  made  on  a  living  person,  and  perhaps  rudiments  of  the  uterus  and  the  tubes 
may  have  been  present. 


i.rrEiiATi'Ri':.  281 

Maykkikifkk,  ('.:  "  Entwii-kfliiii^'slVliUr  di-r  ( iil);iriiiiitt«.'r"  {IHIIidIIi's  Fnuiinhnink- 

fu'ilfii,  vol.  i.  part  2). 
Mkadows:  "A  Case  oi"  Inf;\iiiial  Ilfniiaof  tliu  Ki;,'lit  ( )v;irv  siicccssriilly  Removed" 

(Loud.  Ohnl.  TntiiK.,  ISd'J,  vol.  iii.  p.  4;Wl. 
MeyKR.  L.  :    lHt'rin{ti/(/<li)iniiuiicsoinSlcrtlil<tti(utrs(t>/,  (ji[)C'iiliaf^on,  1S80. 

:    Ih't  yonnulc  SntiK/crxk-db,  Fiidurl  off  Jiarst'lKiiuj,  ( 'opfiihagen,  1882. 

Moldkxiiaukr:    "  Ein  hesoiuleiur  Fall  von  8c'li\vaiif?frsiliatl  in   eiiier  c'inli(">inij,'fn 

(iol):iriuutter"  (Arch.  J'iir  Gyniik:,  1S7'),  vol.  vii.  \).  ITo). 
Mo.s-<MANN,  B.  E. :  "A  Case  of  Congenital  Atresia  of  the  Vagina"  (.!;«.  Jonrn.  Olntt., 

18S1,  vol.  xiv.  p.  564). 
Mow  AT,  G. :  "A  Case  of  Apitarcnt  Absence  of  Uterus"  (Loud.  ObM.  Trtinx.,  1878,  vol. 

XX.  p.  289). 
MUNDE,  P.  F. :  "A  Ciuse  of  Single  Uterus  with   Hoiilile  Cervix  and   X'agina"  (Am. 

Journ.  Obst.,  1878,  vol.  xi.  p.  575). 
:  "A  Case  of  Presumptive  True  Lateral  Ilerniaplirodism"  (Am.  Jonrn.  Obnt., 

Feb.,  1876,  vol.  viii.  pp.  615-6ol). 
Nackr:  "Uterus  bioornis  septus,  Vagina  partim  septa,  Hsematometra  dextra,  IIa>nia- 

tosalpinx  dextra,  IlaMnatocolpos,  etc."  (Arch.  J'ilr  Gyndlc,  1876,  vol.  ix.  p.  471). 
Neugebauer,  L.  :  "F^inseitige  Iliiuiatometra  bei  zweitheiligem  Uterovaginalkanale" 

(Arch.  J'iir  Grjndk:,  1871,  vol.  ii.  p.  247). 
Nieberding:  "  Casuistischer  Beitrag  zu  den  Gynatresien  "   (Arch,  fiir  Gynii/c,  1882, 

vol.  XX.  p.  336). 
Nielsen,  P.:  "  Om  Atrofi  af  Uterus"  (Howitz's  Gyncekologische  og  Obsfetricishe  Meddd- 

elser,  Copenhagen,  18S4,  vol.  v.  p.  74). 
Olshausen,  K.  :  "  Die  Krankheiten  der  Ovarien,"  Stuttgart,  1877  (Billroth's  Hamlbuch 

der  Frauenkrankheiten,  vol.  ii.). 
Osterloh:  "Atresia  ani  vaginalis"  (Arch.  f.  Gyncik.,  1875,  vol.  vii.  p.  565). 
Palmer:  "Two  Ilerniaphrodite  Sisters"  (Am.  Journ.  Obnt.,  1880,  vol.  xiii.  p.  174). 
Peaslee,  E.  R.  :  "Case  of  Uterus  Didelphys  Septus  et  Vagina  Septa"  (Am.  Journ. 

Obst.,  1876,  vol.  ix.  p.  651). 

:  "Solid  Uterus  Bipartitus"  (.4m.  Gyn.  Trans.,  1876,  vol.  i.  p.  340). 

PooLEY,  J.  H. :  "On  Imperforate  Anus,  the  Rectum  communicating  with  the  Vagina" 

(Am.  Journ.  Obst.,  Feb.,  1872,  vol.  iv.  p.  676). 
:  "Case  of  Absence  of  the  Uterus  and  Vagina"  (Am.  Journ.  Obst.,  May,  1871, 

vol.  iv.  p.  70). 
Prochownick:  "Fall  von  Menstruatio  pra?cox  mit  Sectionsbericht"  (Arch.  J.  Gynak., 

1881,  vol.  vii.  p.  330). 
Rheinstaedter  :     "Rndimentiire     Entwickelung    weiblicher    Generationsorgane " 

(Arch.  f.  Gyncik.,  1879,  vol.  xiv.  p.  497 1.  * 

Richmond,  J.  M. :  "A  Successful  Operation  for  Atresia  Vaginae"  (Am.  Journ.  Obd., 

1884,  vol.  xvii.  p.  600). 
Roberts,  D.  L.  :  "  Bicorned  Uterus"  (Land.  Obst.  Trcms.,  1872,  vol.  xiii.  p.  312). 
Roger.-;,  L.  :  "A  Case  of  Male  ITermaphrodism  "  (.4??!.  Journ.  Obst.,  1876,  vol.  ix.  p. 

171),  from  Cincinnati  Lancet  and  Observer. 
Rogers,  W.  R.  :  "  Ca.se  of  Vagina  and  Uterus  divided  by  a  Septum  "  (Lond.  Obst. 

Trans.,  1871,  vol.  xii.  p.  29). 
RoKiT.VNSKY  :  "  Verhandlungen  der  "Wiener  Gesellschaft  der  Aerzte  "  (  Wiener  Medi- 

cinische  Wochenschrij't,  1869,  p.  724). 
Rose,  Cooper  :  "  Case  of  Extravasation  of  the  Bladder,  Absence  of  the  Rectum,  the 

Colon  opening  through  the  wall  of  the  Ectopic  Bladder,  Absence  of  the  Symphysis 

Pubis,  and  the  Development  of  the  Uterus  in  Two  Lateral  Portions"  (Lond.  Obst. 

IVan.s.,  1874,  vol.  xv.  p.  128). 

■- :  "Case  of  Extreme  Hypospadias"  (Lond.  Obst.  Trans.,  1877,  vol.  xix.  p.  256). 

RorTH,  C.  H.  F. :  "  Case  of  Absence  of  Vagina,  with  Retained  Menses  in  Utero  and 

Fallopian  Tubes"  (Lond.  Obst.  Trans.,  1871,  vol.  xii.  p.  34). 


282  MALFORMATIONS  OF  THE  FEMALE   GENITALS. 

Eouth:  "Case  of  Bilocular  Uterus "  ^  {Lond.  Obsl.  Trans.,  1871,  vol.  xii.  p.  295). 

Sappey,  p.  :   Traite  dJ Anatomic  descriptive,  Paris,  1857-64. 

ScHATZ,  F. :  "  Sieben  Falle  von  unvollkommener  Vereinignug  des  weiblichen  Geni- 

talkanales  bei  Erwachsenen"  [Archiv far  Oyndk,,  1871,  vol.  ii.  p.  289). 
:  "Ein  besonderer  Fall  von  Misbildung  des  weiblichen  Urogenital  systems" 

{Arch.filr  GyniiL,  1872,  vol.  iii.  p.  304). 

"Geburt  eines  Monstrums.  Drei  Falle  von  einhornigem  Uterus "  (Arch,  far 


GynaL,  1870,  vol.  i.  p.  153). 
ScHoriELD,  E.  H.  A.:  "The  Delivery  of  a  Monster"  {Lond.  Obst.  Trans.,  1879,  vol. 

xxi.  p.  71). 
SCHROEDER,  C. :  Handbuch  der  Krankheiten  der  weiblichen  Geschlechtsorgane,  Leipzig, 

1874. 
Simpson,  J.  Y. :  "Hermaphroditism"  {Obstetric  Works,  vol.  ii.  pp.  203-328,  Philadel- 
phia, 1856). 
SiPPEL,  A.:   "Ein  Fall  von  schwieriger  Geschlechtsbestimmung"  {Arch.  f.  Gyndk., 

1879,  vol.  xiv.  p.  168). 
Smith,  A.  G. :  "  The  Position  of  the  Hvmen  in  the  Negro  Race  "  {Am.  Journ.  Obst., 

1877,  vol.  X.  p.  638). 
Smith,  H.  :    "A  Case  of  Delivery  through  an  Imperforate  Vagina"    {Lond.    Obst. 

Trans.,  1881,  vol.  xxiii.  p.  117). 
Squarey,  O.  E.  :  "Three  Sisters  in  whom  the  Uterus  and  Ovaries  were  Absent" 

(Lond.  Obst.  Trans.,  1873,  vol.  xiv.  p.  212),  with  other  cases  mentioned  in  the  dis- 
cussion. 
Stadfeldt,  a.  :  "  Nogle  Tilfselde  af  Misdannelser  i  Genitalkanalen  hos  Kvinden " 

{Howitz's  Meddelelser,  vol.  ii.  p.  24,  Copenhagen,  1879). 
Svp^ASEY,  E. :  "An  Interesting  Case  of  Malformation  of  the  Female  Sexual  Organs" 

{Am.  Journ.  Obst,  1881,  vol.  xiv.  p.  94). 
Tait,  L.  :  "Hermaphroditism"  {Am.  Oyn.  Trans.,  1876,  vol.  i.  318). 
Tardieu,  a.:  Etude  Medico-legale  .sur  les  Attentats  aux  Mceurs,  Paris,  1878. 
Taylor,  I.  E. :  "  Atresia  of  the  Vagina,  Congenital  or  Accidental,  in  the  Pregnant 

or  Non-Pregnant  Female"  {Am.  Gyn.  Trans.,  1879,  vol.  iv.  p.  404). 
Teller,  S.  :  "Repeated  Pregnancy  in  a  Uterus  Bicornis"  {Am.  Journ.  Obst.,  1884, 

vol.  xvii.  p.  142). 
TuRNiPSEED,  E.  B. :  "  Some  Facts  in  Regard  to  the  Anatomical  Difference  between 

the  Negro  and  White  Races"  {Am.  Journ.  Obst.,  1877,  vol.  x.  p.  32). 
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1875,  vol.  viii.  p.  515). 
Watts,  R.:  "Case  of  Double  Vagina  with  Single  Uterus"  {Am.  Joarn.  Obst.,  1877, 

vol.  X.  p.  279). 
Werner,  M.  B.  :  "Battey's  Operation  Performed  in  a  Case  of  Malformation  of  the 

Generative  Organs"  {Am.  Journ.  Obst.,  1884,  vol.  xvii.  p.  144.). 
Werth  :  "Rudimentare  Entwickelung  der  Miillerschen  Giinge  Doppelseitige  Hernia 

ovarialis  inguinalis"  {Arch.  f.  Gyndk.,  1877,  vol.  xii.  p.  132). 
Whittaker,  J.  T. :  "Agenesis  Urethras,  etc."  {Am.  Journ.  Obst.,  1870,  vol.  iii.  p.  389). 
Wilson,  H.  S.:  "Notes  on  a  Foetus"  {Lond.  Obst.  Trans.,  1879,  vol.  xxi.  p.  58). 
WiNCKEL,  F. :  Die  Pathologic  der  Weiblichen  Sezualorgane,  Leipzig,  1881. 
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Gyndk.,  1870,  vol.  i.  p.  190). 

1  Seems  to  be  a  uterus  bicornis  uniforis. 


GYNECOLOGICAL  DIAGNOSLS. 

By  EGBERT  H.  GKANDIN,  A.  H.,  M.  \)., 
Nkw   York. 


The  (Ha<>;n()sis  of  disease  of  the  feiiiule  <>('ii('rative  or<^ans  is  b&set  by 
peculiar  difficulties  to  which  no  other  branch  of  medicine  can,  in  the 
same  degree,  lay  claim.  The  organs  of  generation  in  the  female  are 
protected  from  scrutiny,  at  the  outset,  by  that  inherent  modesty  which 
causes  woman  to  rebel  against  the  mere  thought  of  examination,  and 
furthermore,  these  organs  are  so  situated  that  it  is  largely  by  the  sense 
of  toucli,  direct  or  indirect,  that  deviation  from  the  normal  is  to  be 
detected.  The  intimate  connection  also  which  exists  between  the 
sexual  and  other  systems  of  the  human  body  can  but  increase  the 
obstacles  in  the  way  of  localization  of  disease,  necessitating,  therefore, 
the  use  of  the  judicial  faculty  in  a  peculiarly  high  degree.  The  gyne- 
cologist hence  must  possess,  aboye  all,  tact,  delicacy  of  touch,  and  that 
broadness  of  mind  which  will  allow  of  his  looking  beyond  the  organs 
he  habitually  treats,  in  the  recognition  of  the  fact  that  symptoms  point- 
ing to  the  uterus  do  not  necessarily  mean  disease  of  that  organ,  and, 
what  is  ('(iually  true,  that  serious  uterine  disease  may  be  masked  under 
symptoms  directing  attention  to  some  other  organ  of  the  body.  The 
broad  truth  must  not  be  lost  sight  of  that  gynecology  is  but  a  part  of 
a  grand  whole.  Its  basis  is  medicine,  and  it  is  irrational  to  enter  on 
its  practice  without  ever  bearing  in  mind  that  it  is  but  a  link  in  a  com- 
plex chain,  which,  lengthened  in  time,  and  still  lengthening,  necessarily 
requires  subdivision  that  each  link  may  be  better  forged,  each  part  more 
fitly  adapted  to  the  whole.  Therefore  the  natural  origin  and  the  need 
of  the  '^  specialties,"  and  therefore  the  too-little  recognized  truth  that  he 
will  make  the  most  successful  gynecologist  who  has  first  been  a  general 
practitioner,  and  also  that  the  latter  cannot  hope  to  vie  with  the  former 
without  thorough  and  systematic  training  in  the  special  manipulation 
which  belongs  properly  to  modern  gynecology. 

Toward  the  diagnosis  of  disease  of  the  female  generative  organs  we 
are  assisted,  even  as  in  other  branches  of  medicine,  by  the  history  of 
the  patient,  whereby  we  obtain  the  rational  signs,  and  by  the  local 
examination,  whereby  we  negative  or  confirm  the  diagnosis  suggested 

283 


284  GYNECOLOGICAL  DIAGNOSIS. 

by  these  rational  signs.  These  two  divisions  I  shall  consider  separately^ 
first  premising,  in  a  general  way,  that  the  symptomatology  should  never 
carry  too  much  weight,  for  woman,  especially  Avhen  the  victim  of  fan- 
cied disease,  will  deceive  not  only  herself,  but  also  her  physician  if  per- 
chance his  credulity  be  stronger  than  his  judgment. 

Rational  History. 

In  obtaining  the  rational  signs  it  is  of  great  advantage  to  proceed 
systematically,  and  to  follow  the  same  routine  method  of  questioning 
in  each  case.  For  this  purpose  it  is  Avell  to  have  a  record-book,  where- 
in, under  appropriate  headings,  the  obtained  answers — as  well  as,  later 
on,  the  results  of  the  physical  examination — may  be  recorded.  Each 
one  may  construct  such  a  scheme  for  himself  in  accordance  with  the 
manner  which  experience  teaches  him  is  the  most  appropriate  for  con- 
ducting his  examination.  I  therefore  do  not  deem  it  necessary  to  intro- 
duce one  here.  Sufficient  the  statement  that,  in  general,  our  questions 
should,  at  the  outset,  aim  at  obtaining  from  our  patient  information  in 
regard  to  what  may  be  termed  the  etiological  factors  on  which  may 
possibly  depend  the  symptoms,  which,  later  on,  she  herself  is  to  be 
allowed  to  give.  Our  verbal  examination,  hence,  is  first  direct,  and 
then  indirect. 

By  direct  questioning  we  obtain  answers  to  the  following :  1,  the 
social  position  and  occupation  of  the  patient ;  2,  the  age  and  state 
(whether  married  or  single) ;  3,  the  number  of  children  and  miscar- 
riages ;  4,  the  health  of  parents  and  previous  personal  health ;  5,  the 
performance  of  the  menstrual  function ;  6,  the  date  of  appearance  of 
symptoms. 

The  answers  given  to  these  questions  obviously  have  an  important 
bearing  on  the  further  history  of  the  case,  and  will  govern  us,  in  a 
measure,  in  our  decision  as  to  the  necessity  of  a  local  examination. 
With  the  maiden,  for  instance,  Ave  may  usually  at  once  eliminate  dis- 
eases the  followers  of  childbearing  and  of  impure  or  inordinate  coitus, 
and  direct  our  questions  toward  ascertaining  the  state  of  the  general 
health  and  the  performance  of  the  menstrual  function.  Knowledge 
of  the  social  position  and  occupation  of  our  patient  is  of  value,  since, 
obviously,  that  which  is  laborious  or  of  a  confined  nature  is  apt  to 
impress  alterations  on  the  system  either  general  or  local,  and  since,  too, 
habits  of  indolence  or  of  luxmy  carry  ills  in  their  train,  largely,  in  these 
days,  owing  to  the  pernicious  method  of  dress  which  is  in  vogue.  The 
age  of  our  patient  is  particularly  of  value,  as  allowing  the  exclusion  of 
those  new  growths  the  tendency  toward  which  increases  with  age,  as 
also  as  indicating  to  us,  in  certain  cases,  the  prognosis  as  regards,  it 
may  be,  sterility,  it  may  be  the  disappearance  of  some  symptom  the 


Jt.llloy.lL    IIISTOIIY.  285 

rclirl' trom  which  iii;i\  oiiK  he  lonkcd  liir;!!  the  iiicii<i|»;iil-c.  The  state 
jiikI  the  a^c  lom'thci' arc  to  he  taken  into  consideration  in  oim"  decision 
as  to  the  necessity  ola  local  examination  ;  and  I  wonid  sav  here  thai  in 
the  nnniarricd  it  is  exceptional  that  an  examination  is  reijnisite  nntil 
e-enerai  eonslitntional  measiu'es  have  heen  tried  withont  avail.  < )!" 
eoin-se  I  exchide  from  this  dietiim  fnier<^eueies,  sueii  a.s  .sudden  heni- 
orrhan'e  or  symptoms  pointin<i;  so  dearly  to  the  sexual  organs  that  our 
])ast  e.\j)erienee  teaches  ns  it  is  hut  tolly  to  temporize. 

With  the  married,  on  the  other  hand,  whilst  we  must  guartl  ourselve.s 
auaiust  the  assumption  that  there  necessarily  exists  disease  of  the  gene- 
rative oro-ans,  our  line  of  questioning  nuist  be  widely  diifereiit.  The 
fulfilment  of  the  ]nirposes  for  which  marriage  Ava.s  instituted  too  fre- 
(piently  entails  functional  or  organic  derangement,  and,  as  it  is  our 
business  to  use  every  proper  means  for  the  detection  of  al)normalities, 
we  need  not  be  too  chary  in  our  speech — indeed,  must  sometimes,  to 
fulfil  our  ^\•hole  duty,  even  ask  questions  which  touch  upon  the  mo.st 
delicate  possible  ground.  Such  arc — the  frequency  of  intercourse,  the 
sensations  evoked,  the  completeness  or  incompleteness  of  the  act,  the 
retention  or  non-retention  of  the  semen :  these  are  questions  the  answers 
to  which  Avill  frequently  give  ns  a  clue  to  the  cause  of  mcnstnial 
derangement  or  the  possible  cause  of  sterility. 

If  the  patient  be  married,  information  must  next  be  sought  in  regard 
to  the  numl)cr  of  children  or  miscarriages  she  has  had,  of  the  interval 
which  has  elapsed  since  the  last  delivery,  as  to  the  duration  of  the  sev- 
eral labors,  instrumental  interference,  length  of  the  puerperium,  and 
incidents  jjeculiar  to  it.  We  are  thus  often  led  to  suspect  that  our 
local  examination  will  reveal  some  injury  to  the  genital  tract,  or  pelvic 
exudation  recent  or  chronic — a  suspicion  which  obviously  influences 
strongly  in  the  decision  as  to  the  necessity  of  a  local  examination.  It 
is  important  also  to  question  our  patient  in  regard  to  the  function  of 
lactation,  on  account  of  the  very  decided  influence  which  its  due  and 
jM'opcr  performance  has  on  uterine  involution.  In  case  of  one  or  more 
miscarriages,  we  must  determine  as  accurately  as  possible  the  month  at 
which  they  occurred,  ascertain  the  probable  cause  and  the  manner  of 
eare  the  patient  received,  and,  where  habit  is  the  probable  factor,  seek 
behind  this  convenient  term  for  the  real  factor  in  order  to  scientifically 
bring  to  bear  on  its  cure  every  possible  means  at  our  disposal,  including, 
of  course,  examination  and  treatment  of  the  husband  in  those  cases,  by 
no  means  infrequent,  where  he  must  bear  the  partial  or  entire  onus  of 
premature  ])Hghting  of  the  ovum.  In  this  connection,  too,  it  should 
ever  be  borne  in  mind  that  the  abuse — or,  strictly,  the  use — of  certain 
means  for  the  prevention  of  conception  at  such  times  when  offspring  are 
not  desired  frequently  acts  like  a  double-edged  sword,  and  through  its 
injurious  etTcets  on  the  sexual  organism  prevents  the  bringing  to  term 


286  GYNECOLOGICAL  DIAGNOSIS. 

of  the  ovum  which  has  been  fructified  designedly.  These  means  may, 
therefore,  be  indirectly  responsible  for  miscarriage,  so  that  the  question 
is  pertinent  whether  they  are  resorted  to. 

Inquiry  in  regard  to'the  health  of  our  patient's  parents  is  too  often 
neglected,  and  yet  is  of  great  importance.  Whilst  the  influence  of 
heredity  has  never  as  yet  been  distinctly  formulated,  there  are  suflicient 
data  at  our  disposal  to  warrant  the  assertion  that  ancestral  disease  may 
so  modify  the  nutrition  and  configuration  of  the  offspring  as  to  render 
it  more  accessible  to  disease,  even  if  this  be  not  directly  implanted. 
The  so-called  scrofulous  taint  may  unquestionably,  in  a  latent  form,  be 
responsible  for  deviation  from  health  in  the  genital  system,  even  as  it 
is  in  other  departments  of  the  body ;  and  the  like  holds  true  of  other 
constitutional  diseases  which  we  are  prone  to  look  upon  as  hereditary. 
I  rank  this  question  as  an  important  one  advisedly,  because  I  know 
that  through  a  proper  appreciation  of  its  import  very  frequently  the 
prognosis  and  the  treatment  of  apparent  disease  of  the  genital  system 
will  depend  upon  and  lie  through  constitutional  measures  rather  than 
local. 

And  this  remark  holds  true  as  well  of  an  associated  question — the 
previous  state  of  health  of  the  patient  herself.  Much  valuable  informa- 
tion, and  in  an  obscure  case  very  necessary,  may  be  gleaned  from  close 
questioning  on  this  point.  A  sore  throat  and  loss  of  hair  following 
closely  on  marriage  may,  in  the  absence  of  certain  positive  signs,  but 
taken  in  connection  with  slight  negative,  offer  a  probable  explanation 
for  frequent  miscarriage.  The  parenchymatous  degeneration  of  the 
muscles  which  accompanies  high  febrile  states  not  improbably  may 
modify  the  organs  of  generation  sufficiently  to  prevent  their  normal 
function.  These  remarks  are  simply  made  to  indicate  the  line  of 
thought  which  answers  to  this  question  might  suggest :  to  discuss  the 
subject  at  length  w^ould  lead  me  entirely  too  far. 

We  are  next  to  obtain  the  menstrual  history  of  our  patient.  In  the 
young  and  unmarried  it  is  usually  derangement  of  the  menstrual  func- 
tion which  brings  the  patient  to  the  gynecologist — it  may  be  amenor- 
rhoea,  it  may  be  irregularity  in,  or  pain  during,  the  performance  of  the 
function.  These  are  the  very  cases  in  which  there  is  difficulty,  espe- 
cially, in  deciding  as  to  the  necessity  of  a  local  examination.  I  would 
again  strongly  deprecate  recourse  to  a  local  examination  in  the  unmar- 
ried before  the  special  features  of  the  case  have  been  carefully  sifted, 
and  varied  and  prolonged  attempts  have  been  made  by  means  of 
general  constitutional  measures  to  relieve  what,  in  the  young  and  grow- 
ing maiden,  is  often  due  to  method  of  life  or  to  chlorosis.  Nothing  but 
very  urgent  symptoms  should  justify  local  examination  of  the  young 
girl  who  has  scarcely  passed  the  pubescent  period.  In  her,  derange- 
ment of  menstruation,  such  as  skipping  a  period,  dysmenorrhoea,  con- 


liATiosAL  iiisronv.  287 

«i|;('stive  si^ns  due  to  scanty  How,  arc  not  necessarily  pathological  factors. 
It  takes  time  for  the  nicnstrnal  liahit  to  become  rejruhirly  and  normally 
ac(|uired  ;  and  where  an  examination  is  needlessly  resorted  to  an  ludookt'd- 
for  effect  may  be  profound  injury  to  the  maiden's  morale.  There  is, 
however,  a  i:;rou|)  of  symptoms  which  shoidd  ever  speak  in  favor  of  a 
local  examination,  and  this  is  constituted  by  the  conjoined  factors  amcnor- 
rhoea,  eoni>;estive  signs,  and  molimina.  The  regidar  recurrence  of  these 
symptoms  shoidd  suj::gest  possible  occ-lusion  of  the  vagina  with  reten- 
tion of  menses — a  c<»ndition  calling  for  early  resort  to  operative  inter- 
ference. 

Our  questions  concerning  menstruation  should  be  in  regard  to  the 
age  at  which  the  function  was  established,  the  regularity  with  which 
the  flow  recurs,  the  duration,  amount,  and  character  of  the  flow,  the 
presence  of  pain  before,  during,  or  after  the  flow,  and  the  date  of  the 
last  menstruation.  If  amenorrhcea  be  complained  of,  we  should  always 
bear  in  mind  the  physiological  cause,  and  suspect  pregnancy  until  we 
have  for  ourselves  disproved  it.  In  exceptional  cases,  however,  amenor- 
rhcea will  only  apparently  exist,  for  on  close  questioning  the  fact  will 
be  revealed  that  for  a  number  of  days  each  month  there  is  an  increased 
white  discharge  which  the  patient  takes  for  an  aggravation  of  her  leu- 
corrhcea,  but  which  the  physician,  in  case  there  be  accompanying 
molimina,  will  recognize  as  the  so-called  white  menses,  and  thereby 
essentially  modifs'  his  prognosis.  The  presence  of  molimina  also  assists 
us  in  our  diagnosis  and  prognosis  of  those  cases  of  amenorrhcea  where 
the  local  examination  reveals  an  undeveloped  state  of  the  uterus  or  ovaries. 
The  number  of  days  during  which  the  flow"  lasts,  its  amount  (deter- 
mined in  our  better  classes  by  the  average  niunber  of  napkins  worn), 
the  presence  of  clot  or  of  membrane  in  the  flow, — are  all  questions  bear- 
ings on  our  diagnosis  and  ultimate  method  of  treatment.  If  menstrual 
pain  be  complained  of,  it  is  important  to  time  its  rhythm — that  is  to 
say,  to  determine  whether  the  pain  precedes,  accompanies,  or  follows 
the  flow — for  thus  we  are  in  a  position  to  decide  whether  the  probable 
cause  be  uterine  or  ovarian.  It  is  almost  supei-fluous  to  state  that  it  is 
always  essential  to  know  the  date  of  the  patient's  last  period,  although 
undue* weight  is  never  to  be  given  to  lier  statement  on  this  point  should 
the  local  examination  give  us  cause  to  think  that  the  patient  is  either 
endeavoring  to  deceive  us,  or  else  that  the  discharge  at  the  last  stated 
period  occurred  notwithstanding  the  presence  of  an  impregnated  ovum 
within  the  uterus. 

The  last  question,  the  length  of  time  since  the  appearance  of  the 
symptoms,  has  in  part  an  etiological  bearing  and  in  part  a  diagnostic. 
In  the  young  unmarried  female  a  common  starting-point  of  symptoms 
is  imprudence  during  menstruation.  By  imprudence  I  refer  not  alone  to 
the  neglect  of  avoidance  of  causes  which  result  in  checking  this  phys- 


288  GYNECOLOGICAL  DIAGNOSIS. 

iological  function,  and  yet  such  a  disagreeable  function  in  so  far  as  it 
often  interferes  with  the  plans  and  wishes  of,  especially,  our  young 
maidens  of  higher  social  life :  my  meaning  is  still  broader,  including 
as  it  does  the  general  neglect  of  proper  rest,  both  mental  and  physical, 
at  the  time  of  the  periods  the  most  critical  of  all — the  year  or  so  fol- 
lowing the  establishment  of  puberty.  Derangements  of  menstruation, 
chronic  congestion  and  displacements  of  the  pelvic  organs,  ovaralgia 
and  ovaritis, — such,  in  their  ensemble,  are  the  pathological  factors  which 
may  be  traced  to  neglect  of  rational  precautions  during  menstruation. 
In  the  married,  symptoms  very  frequently  may  be  traced  to  abuse  of 
the  sexual  act.  This  is  particularly  noticeable  in  the  newly-married, 
in  whom  symptoms  will  be  found  to  dejDend  on  the  constant  state  of 
congestion  in  which  the  pelvic  organs  are  kept.  Thus  are  explainable, 
often,  menorrhagia  dating  from  the  time  of  marriage,  ovaralgia,  back- 
ache, dragging  pains  in  the  abdomen,  vague  hystero-neurotic  symptoms. 
A  further  cause  of  symptoms  in  the  married  is  the  resort  to  means  for 
the  prevention  of  conception — in  particular,  I  believe,  vaginal  injections 
taken  immediately  after  the  sexual  act,  and  in  such  haste  that  the  tem- 
perature of  the  water  is  not  attended  to,  and  in  consequence  the  conges- 
tion naturally  following  the  sexual  act  receives  sudden  and  harmful 
check.  Again,  the  measures  resorted  to  by  far  too  many  married 
women  to  destroy  the  undesired  fruit  of  the  womb  obviously  can  but 
react  unfavorably  on  the  pelvic  organs.  Abuse  of  function  invariably 
leads  to  pathological  alteration :  in  order  to  determine,  therefore,  the 
degree  to  which  pathology  has  affected  the  sexual  organism  of  our 
patients  it  is  necessary  to  know  not  only  the  cause  of  symptoms,  but, 
as  far  as  possible,  the  length  of  time  during  which  such  cause  has  been 
at  Avork.  Thus  it  is  that  even  through  questioning  which  bears  more 
particularly  on  etiology  we  are  assisted  toward  correct  diagnosis. 

I  have  now  sketched  briefly  the  nature  of  what  may  be  termed  the 
preliminary  questions,  and  I  pass  to  the  consideration  of  symptoms 
of  which  the  patient  complains  or  which  are  drawn  out  by  the  exam- 
iner. And  here  I  would  remark  that  there  are  but  few  symptoms 
which  singly  can  properly  be  regarded  as  peculiar  to  disease  of  the 
female  pelvic  organs.  It  is  only,  usually,  when  taken  in  their  ensem- 
ble that  they  justify  the  inference  that  there  exists  organic  or  functional 
derangement.  And  even  as  symptoms  of  themselves  are  so  deceptive, 
so  too  should  Ave  carefully  gauge  our  patient,  lest  she  endeavor  to  de- 
ceive us  for  a  purpose  or  is  in  reality  deceiving  herself.  Desire  for 
sympathy,  the  impulses  of  hysteria,  the  wish  which  is  often  the  father 
to  the  thought, — are  each  incentives  in  the  making  of  a  plausible  his- 
tory, the  Avorth  of  Avhich  it  rests  AAath  the  physician  to  decide.  I  do 
not  mean  that  he  is  not  to  give  credence  to  the  symptoms  unless  he  can 
find  a  cause ;  I  Avould  simply  Avarn  against  alloAving  a  skein  of  symp- 


RATIOS M.  iiisronv.  28J> 

toras  skilfully  woven  t<i  lead  tlir  |)('i(<|)ti(tii  ami  jiirluriiciit  awav  IVoiii 
that  wliicli  really  exists.  It  is  well  t<t(i  to  allow  tlie  patient  to  tell 
her  own  story — a  tedions  inetluMl,  eei-tainly,  hut  one  tlirougli  wliieli  we 
are  more  a|)t  to  reaeli  the  exact  trntli  than  if  lea<lin^r  (jiiestioiis  were 
])nt.  Of  course,  alter  the  j)atient  has  told  us  all  she  can  or  will,  it  rests 
with  the  exaniinei-  to  till  in  thi'  »i:aj)s,  and  thereby  jxissibly  obtain  infor- 
mation which  has  been  concealed. 

In  <i-cneral,  the  symptom  w  hicji  ordinarily  drives  the  patient  to  eoii- 
sidt  the  uynecolo<;ist  is  pain.  This  pain  may  be  in  various  [)ai1:s  (;f  tiie 
body,  and  it  is  its  association  w  ith  (ttln-r  syniptom>  emanating  from,  or 
so  situated  as  to  suiTLTCst  their  oriiiinati<jn  in,  some  portion  of  the  jreiiital 
system  which  attracts  attention  to  the  pelvic  organs.  Pain  in  the  Imck, 
lumbar  or  sacral,  is  a  symptom  common  to  the  majority  of  women,  and 
evidently  its  cause  may  be  entirely  independent  of  the  uterus  or  its 
adnexa.  The  lifting  of  heavy  weights,  occupations  which  reipiire  j)ro- 
longcd  flexion  of  the  triuik  on  the  pelvis,  the  injudicious  use  of  the 
sewing-machine, — these  are  amongst  the  possible  causes  which,  if  per- 
sisted in,  imdoubtedly  will  lead  to  local  pelvic  disorder.  When  the 
pain  is  chronic,  however,  sacral  in  site,  and  particularly  Avhen  it  is 
associated  with  dragging  or  bearing-down  sensations  in  the  abdomen, 
then  it  rises  to  a  higher  level  as  a  diagnostic  factor,  and  our  local 
examination  will  in  all  probability  reveal  some  displacement  of  the 
nterus,  injury  to  the  pelvic  floor,  or  interference  with  the  circulatifjn 
through  the  pelvic  organs.  Pain  in  the  nates,  running  down  the 
dorsum  of  the  thigh,  will  usually  find  its  explanation  in  sciatica,  but 
if  other  factors  in  the  history  point  to  recent  or  chronic  inflammatorv 
pelvic  exudate,  this  pain  may  find  its  explanation  in  the  same  cause. 
Pain  in  the  abdomen  is  next  in  frequency  to  pain  in  the  back ;  and  here 
we  must  determine  its  site,  its  constancy  and  duration,  and  its  nature. 
Suprapubic  pain  will  direct  attention  to  the  bladder,  and  it  will  remain 
for  future  examination  to  determine  whether  this  organ  is  directlv  at 
fault,  or  indirectly  through  the  mechanical  pressure  of  the  uterus  or  a 
foreign  growth.  Diffuse  abdominal  pain,  accom])anied  In*  distension, 
suggests  intra-alxlominal  growths  oi-  fluid  or  affections  of  the  perito- 
neum. Pain  in  the  iliac  or  ovarian  regions  is  a  frequent  svmptom  ; 
and  this  pain  is  more  frequently  situated  to  the  left  than  to  the  right. 
While  the  local  examination  may  reveal  ovarian  or  obscure  tubal  dis- 
ease, this  ])ain  is  often  present  without  adequate  explanation,  so  that  its 
exact  value  as  a  diagnostic  factor  is  not  settled.  In  character  it  is  usu- 
ally either  burning  or  lancinating ;  and  in  tlie  latter  instance  we  will 
often  be  led  to  surmise  tubal  disease.  In  a  large  ]iro]->ortion  of  cases 
I  have  found  pain  in  the  left  ovarian  region  dependent  purelv  on 
chronic  constipation,  as  evidenced  by  the  fact  that  the  pain  entirelv  dis- 
appears on  the  patient  acquiring  the  habit  of  daily  defecation.  The 
Vol.  I.— 19 


290  GYNECOLOGICAL  DIAGNOSIS. 

explanation,  of  course,  of  this  association  of  pain  and  loaded  rectum -is 
simple  when  we  remember  how  closely  adjacent  to  the  rectum  lies  the 
left  ovary,  and  how  this  latter  organ  will  naturally  suffer  from  the 
pressure  of  the  feces  and  from  irritation  by  the  scybala  as  they  pass 
downward.  A  curious  point  in  connection  with  pain  emanating  from 
the  ovaries  is  that  the  site  of  the  pain  not  infrequently  does  not  corre- 
spond to  the  affected  organ.  In  other  words,  a  left  ovaritis  is  often 
accompanied  by  pain  in  the  right  ovarian  region,  and  vice  versa. 

Pain  from  both  the  back  and  abdomen  frequently  extends  into  the 
legs,  and  is  to  be  considered  as  purely  reflex  in  nature.  Abdominal 
pain  above  the  umbilicus  will  suggest,  of  course,  organic  or  functional 
derangement  of  one  or  another  of  the  abdominal  viscera  according  to 
its  site,  although  here  as  well  the  pain  may  be  reflex  from  the  pelvic 
organs.  If,  instead  of  pain  in  the  abdomen,  enlargement  is  complained 
of,  our  object  should  be  to  ascertain  the  length  of  time  the  enlargement 
has  existed,  in  what  portion  of  the  abdomen  it  first  began,  whether  it 
be  permanent  or  not.  The  importance  of  these  questions  is  apparent, 
particularly  in  connection  with  the  differential  diagnosis  of  abdominal 
tumors. 

Pain  in  the  head  can  scarcely  lay  claim  to  a  place  in  the  symptoma- 
tology of  disease  of  the  pelvic  organs,  unless  it  be  on  account  of  the 
frequency  with  which  women  complain  of  it.  Its  cause  in  the  major- 
ity of  instances  is  constipation  or  chronic  congestion  of  the  pelvic 
organs ;  and  in  these  instances  the  site  of  the  pain  is  usually  the 
occiput.  Rarely  a  hemicrania  will  apparently  depend  on  inflamma- 
tion of  one  or  the  other  ovary,  as  is  attested  by  its  disappearance  as 
the  inflammation  abates. 

Pain  in  the  chest,  if  neuralgic,  may  emanate  from  disorder  of  the 
pelvic  organs,  but  usually  this  symptom  will  call  for  careful  auscul- 
tation and  percussion  at  the  hands  of  the  gynecologist,  even  as  it  would 
were  the  patient  instead  consulting  a  general  practitioner.  Shooting 
pains  through  the  mammse  and  enlargement  of  these  organs  will  suggest 
at  once  pregnancy,  but  both  these  symptoms  may  accompany  uterine  or 
ovarian  disease. 

Pain  in  sitting  should  direct  attention  to  the  coccyx,  or  it  may  result 
from  anal  or  rectal  trouble ;  and  the  aggravation  of  sacral  or  abdominal 
pain  in  standing  or  walking  bears  testimony  to  the  probable  existence 
of  some  uterine  displacement  or  sagging  of  the  pelvic  floor. 

Pain  on  coitus,  or  dyspareunia,  is  a  symptom  which  ordinarily  the 
patient  will  not  mention  of  her  own  accord.  This  symptom  is  a  fre- 
quent cause  of  marital  infelicity,  and  is  therefore  a  sufficient  justification 
in  itself  for  requesting  a  local  examination.  The  cause  we  are  not 
always  able  to  discover,  but  often,  aside  from  disproportion  in  size 
between  the  male  and  female  organs,  the  local  examination  will  reveal 


IlATloSM.    IIISTniiw  2!»1 

cai'iiiiflcs  ot"  tlir  untliiM,  a  (li>|tl.it((|   iitmis  or  ovarv,  a  >iiii|)lc  li\  (x-r- 
cestlu'sia  atoi*  witliin  the  ostiimi  vauiiia.',  an  anal  fissure,  or  rectal  diseaH', 

From  the  intimate  syni|)atlietie  relations  between  the  stcunaeh  and 
the  peKie  orj^ans  pain  in  the  i'j)i<;astrie  region  is  a  fre(jnent  svniptoin. 
Obviously,  tiiis  ])aiii  may  depend  on  organic  disease  of  the  stomaeh,  and 
cidls  for  careful  differentiation  on  the  part  of  the  <ryneeoIo<rist.  A  dys- 
jH'psia  purely  i'nnctional  in  character,  however,  and  evidence<l  by  either 
simple  j)ain  or  l)y  nausea  or  vomiting,  will  fretjuently  l)e  of  reflex  nature 
from  the  pelvis,  and  will  suggest  in  the  first  j)laee  pregnancy,  particu- 
larly if  these  symptoms  are  matutinal  and  before  eating;  and  in  the 
seeond  place,  ovarian  disease.  Of  course  these  symptoms  may  result 
from  mechanical  jnvssnre  of  some  abdominal  tumor  on  the  stomach, 
but  then  there  will  be  the  further  history  of  abdominal  enlargement, 
and  our  local  exaiuiiiatinii  will  readily  detect  the  cause  of  the  digestive 
disturi)ance. 

Symptoms  poiming  to  the  bladder  and  the  rectinn  are  too  frequently 
denied  the  imi)ortance  they  deserve.  It  is  a  fact  on  which  sufficient 
stress  cannot  be  laid  that  disease  situated  in  the  latter  organ  may,  espe- 
cially in  symj)to!uatology,  very  closely  sinuilate  disease  of  the  reproduc- 
tive organs,  and  the  neglect  of  a  proper  appreciation  of  the  bladder 
symptoms  may  load  the  gynecologist  far  astray  from  the  existing  jiatho- 
logical  factor,  ^^'ilil^t  I  cannot  go  so  far  as  to  say  that  a  chemical  and 
microscopical  examination  of  the  urine  should  be  made  in  ever}'^  case, 
the  same  rule  will  hold  in  gynecology  as  in  other  dejiartments  of  medi- 
cine— that  the  history  of  no  case  is  complete  until  such  an  exami^lation 
has  been  made.  Certainly,  in  a  case  at  all  obscure  we  may  thus  become 
p.)ssessed  of  very  valuable  information,  and  therefore  every  gynecMogist 
should  be  informed  in  regard  to  the  manner  of  properly  examining  the 
urine.  Women,  as  a  rule,  are  able  to  retain  their  urine  longer  than 
men — not  that  the  capacity  of  the  bladder  is  so  much  greater,  but 
largely  through  the  educational  force  of  habit.  Frequent  micturition, 
therefore,  is  a  symptom  very  likely  to  attract  their  attention,  and  it  is 
surprising  how  frequently  one  hears  the  complaint  without  being  able 
to  formulate  a  cause.  ]Mere  frequency,  aside  from  lesion  of  the  kid- 
neys, will  usually  result  from  mechanical  pressure,  perha])s  of  the 
uterus,  porhajis  of  a  foreign  growth.  Frequency  of  mictin-ition  asso- 
ciated with  scalding  suggests  a  variety  of  causes,  such  as  some  derange- 
ment of  the  urine,  or  cystitis,  cannicles  of  the  urethra  or  at  the  mea- 
tus, or  fissure  of  the  neck  of  the  bladder.  Vesical  tenesmus  suggests 
the  same  causes,  as  also,  not  uncommonly,  a  purely  hypera^sthetic  state 
of  the  few  muscular  fibres  which  constitute  the  so-called  sphincter  of 
the  bladder.  Sacculation  of  the  posterior  bladder  wall  into  the  vagina 
or  the  same  condition  of  the  urethra,  cvstocele  and  urethrocele,  are  fre- 
quent causes  of  trouble  in  micturition,  owing  to  the  irritation  of  the 


292  GYNECOLOGICAL  DLAGNOSIS. 

residual  urine  in  these  artificial  pouches.  Calculus  in  the  female  is  a 
flirther  cause,  giving  rise  to  the  same  symptoms  as  in  the  male.  It 
is  not  alone  sufficient,  however,  to  determine  the  frequency  with  which 
micturition  is  performed  and  the  presence  or  absence  of  pain,  but  we 
miust  also  question  our  patient  as  to  the  color  of  the  urine  and  as  to 
the  presence  of  any  noticeable  sediment.  It  goes  without  saving  that 
constant  dribbling  may  mean,  in  the  female  even  as  in  the  male, 
hyperdistension  of  the  bladder.  If  retention  be  complained  of,  espe- 
cially if  of  recent  occurrence,  the  thought  of  acute  displacement  of  the 
uterus  at  once  presents  itself,  and  the  local  examination  will  verify 
our  suspicion. 

In  regard  to  defecation,  we  should  never  rest  satisfied  with  the  state- 
ment that  the  bowels  move  regularly.  Women  have  verv  peculiar 
ideas  in  regard  to  the  normal  performance  of  this  function,  it  being  no 
uncommon  thing  for  this  necessary  demand  of  nature  to  be  satisfied 
only  at  intervals  of  days.  Our  questions,  therefore,  must  be  direct  as 
to  whether  the  act  is  a  complete  one,  as  to  the  presence  of  blood  or 
mucus  in  the  stools,  as  to  the  presence  and  site  of  pain  before  or  after 
the  act,  as  to  the  regularity  with  which  defecation  is  performed.  The 
answers  to  these  questions  will  frequently  suggest  the  cause  of  ovarian 
pain  previously  complained  of,  foretell  the  existence  of  an  anal  fissure  or 
rectal  ulcer,  and  point  to  the  presence  of  rectal  disease  which  otherwise 
might  be  overlooked  in  our  eagerness  to  explain  the  symptoms  through 
derangement  in  the  sexual  system. 

The  presence  of  vaginal  discharge  next  claims  consideration.  It  is 
not  sufficient  to  know  that  our  patient  has  a  discharge :  the  amount, 
the  color,  the  consistency,  the  odor,  the  persistence  of  this  discharge, 
are  each  factors  of  assistance  in  diagnosis,  and  direct  questioning  is 
usually  necessary  to  obtain  the  desired  information.  The  mere  pres- 
ence of  discharge  is  not.  sufficient  justification  for  a  local  examination. 
A  certain  amount  is  physiological,  and  it  should  ever  be  borne  in  mind 
that  disordered  conditions  of  the  blood  may  give  rise  to  a  leucorrhoea, 
even  as  disease  of  the  vagina  or  uterus  Avill.  In  general,  a  discharge 
trifling  in  amount,  whitish  in  color,  of  watery  consistency,  and  odorless, 
will  yield  to  constitutional  measures,  and  in  the  maiden  the  above  con- 
ditions should  ever  receive  general  treatment  before  subjecting  her  to 
local  examination.  When,  on  the  other  hand,  the  discharge  is  tinged 
with  blood  or  discolored  yellow,  the  inference  is  that  local  disease 
exists,  such  as  erosion  of  the  cervix  or  inflammation  of  the  endomet- 
rium ;  when,  again,  the  discharge  is  sticky,  we  may  at  once  assume  that 
the  muciparous  follicles  which  line  the  cavity  of  the  cervix  are  secret- 
ing abnormally  as  the  result  of  disease  of  the  cervix ;  when,  further, 
the  discharge  is  thick  and  creamy  and  associated  with  painful  micturi- 
tion, we  think  of  disease  of  the  vagina,  possibly  of  an  infectious  nature; 


rnvsiLAL  siass.  2f).T 

wlit'ii,  Hiuilly,  the  patient  tells  iis  that  the  (li.s<'har{^e  is  very  otfensive, 
mali^^iiaiit  disease  or  necrosis  of"  a  l)eni<rn  growtli  snggests  it.self.  In 
women  who  liave  passed  tlie  inenopanse  the  sonree  of  a  discharj^e 
sliould  alwavs  he  sini<j;ht  for  Ux-ally,  and,  it"  watery  and  acrid,  will  he 
found  to  (h'|)end  <tn  atony  ot"  the  vagina,  resnhing  in  the  so-calle<l  sen- 
ile vaginitis;  it"  ot"  the  nature  of  a  hemorrhage  <»r  i"oul,  on  malignant 
disease.  It  l)y  no  means  t'ollows,  however,  that  a  jjatient  has  no  dis- 
charge hecause  she  says  so.  ('ertain  women  do  not  notice  a  di-scharge, 
and  yet  complain  of  pruritus — a  symptom  which  of  itself  suggests  a 
discharge — and  the  local  examination  will  freciuently  in  such  ca.ses 
reveal  a  leucorrlujea  and  its  cause.  If  not,  the  urine  should  at  once  be 
examined  for  sugar,  since  pruritus  of  obscure  origin  not  uncommonly 
is  symptomatic  of  diabetes,  in  which  event  there  probably  exist  the 
further  sym}>toms  of  loss  of  weight  and  polydipsia. 

There  remain  now  to  be  enumerated  those  variable  and  varying 
symptoms  which  properly  belong  to  women  advanced  in  life,  and 
which  are  grouped  within  a  few  years  preceding  and  following  the 
menopause.  The  pains  and  the  aches  are  manifold,  the  hot  Hashes  and 
the  cold  spells  of  frequent  recurrence,  and  it  is  from  the  multiplicity 
and  variability  of  the  symptoms,  taken  in  connection  with  the  patient's 
age  and  menstrual  history,  that  we  are  enabled  to  reach  our  diagnosi-s, 
and  feel  justified  in  applying  to  the  symptoms  that  vague  but  conve- 
nient term,  hystero-neurosis.  ObvioiLsly,  in  these  cases,  a  local  exami- 
nation will  usually  reveal  nothing  abnormal,  and  we  should  guard  our- 
selves against  making  one  without  stronger  reason  than  these  symptoms 
jastify  ;  for  our  object  should  be  not  to  attract  but  to  distract  the  atten- 
tion of  these  patients  as  far  as  possible  from  the  sexual  organs.  Cha- 
racteristic also  of  this  time  of  life  are  the  hemianesthesise  and  hyper- 
sesthesije,  the  periodical  swelling  of  the  abdomen,  the  lump  in  the 
throat,  etc.,  which,  while  symptomatic  of  serious  organic  disorder  to 
the  patient,  are  readily  recognized  by  the  physician  as  neither  of  central 
origin  nor  of  grave  import,  but  as  accompaniments  of  that  ftinctional 
disorder  to  which  the  old  term  *'  hysteria"  must  needs  still  be  applied. 

I  have  now  outlined  the  method  after  which  we  should  obtain  the 
rational  history,  the  nature  of  this  history,  and  the  bearing  which  indi- 
vidual factors  should  have  in  determining  us  toward  making  a  hx-al 
examination.  If,  then,  the  symptoms  justify,  we  thereby  proceed  to 
obtain  our  physical  signs,  which,  taken  in  conjunction  with  the  rational, 
go  to  form  our  diagnosis  and  to  construct  our  prognosis. 

Physical  Signs. 

The  physical  signs  are  obtainable  through  the  local  examination. 
Before  proceeding  to  this,  however,  it  is  essential  to  obtain  what  infor- 


294 


G  YNECOL  0  GICA  L  DIA  GNOSIS. 


mation  is  possible  from  a  study  of  the  appearance  of  the  patient.  By 
this  I  mean  to  search  for  the  signs  whicli  point  to  ansemia,  chlorosis, 
acquired  or  inherited  constitutional  disease.  Should  the  rational  history 
have  directed  attention  to  the  thoracic  organs,  careful  auscultation  and 
percussion  should  be  resorted  to.  Such  a  preliminary  physical  exami- 
nation requires  but  a  moment's  time,  and  yet  may  reveal  signs  which 
will  amply  explain  the  rational  history  and  negative  for  the  time,  per- 
haps render  entirely  unnecessary,  recourse  to  a  local  examination.  The 
face  should  be  questioned  for  the  almost  characteristic  markings  of  ova- 
rian or  malignant  disease.  In  the  unmarried  particularly,  where  the 
rational  history  or  a  glance  at  the  configuration  of  the  abdomen  sug- 
gests the  possibility  of  jDregnancy,  a  step  preparatory  to  requesting  a 
local  examination  is  inspection  of  the  breasts — not  that  the  absence  of 
mammary  signs  should  cause  us  to  negative  the  possibility  of  gestation, 
but  because  the  presence  of  such  signs,  taken  in  connection  with  the 
local  findings,  will  frequently  assist  us  in  forming  an  opinion.  In  a 
word,  the  routine  rule  should  be  to  obtain  every  possible  sign  before 
the  local  examination  is  resorted  to,  because  we  never  know  beforehand 
how  simple  or  obscure  the  case  may  turn  out  to  be,  and  in  the  latter 
instance  any  detail,  however  trivial,  may  be  of  marked  assistance. 

In  order  to  make  a  thorough  and  careful  local  examination  the  gyne- 
cologist needs,  above  all,  a  properly-constructed  table  on  which  his 

patient  may  recline  with  com- 
fort, and  which  may  be  readily 
adapted  to  the  necessities  of  both 
the  dorsal  and  left-lateral  posi- 
tion. I  dismiss  from  considera- 
tion the  many  complicated  chairs 
and  couches  offered  to  the  pro- 
fession. These  are  usually  need- 
lessly elaborate,  and  therefore 
expensive.  An  ordinary  table 
with  gentle  slope  backward, 
provided  with  foot-rests  and 
with  hair  mattress  or  other 
covering,  of  sufficient  height 
not  to  strain  the  examiner,  is 
the  simplest  and  cheapest,  and 
answers  every  purpose,  except 
in  the  left-lateral  position, 
where,  in  the  absence  of  an 
attendant  to  hold  the  speculum,  a  lateral  inclination  of  the  top  of  the 
table  is  practically  a  necessity.  Any  carpenter  may  construct  such 
a  table,  and  therefore  the  physician,  whose  taste  or  means  does  not 


Fig.  111. 


Chadwick's  Table  (fur  dorsal  position). 


Via.  112. 


2U0 


Chadwick's  Table  (ciiiis's  position). 


necessitate  or  allow  a  iiaiKlsomely  appointed  or  upholstered  article,  need 
not  bt'  deterred  I'roni  p(»s.>;essino:  one  of  the  jirinie  prere'^juisites  to  a 
thorough  local  examination.     Those  who  desire  something  handsomer, 


Fig.  113. 


Thomass  Table  as  luiKiineii  I'V  Dr.  B.  H.  DaguLi    i-.i  .i..i>al  position). 

however,  will  find  the  table  devised  by  Thomas,  or  one  of  its  modifi- 
cations, well  adapted  for  gynecological  work.     Among  the  Ix^st  modifi- 


296 


G  YNECOL 0 GICAL  DIA  GNOSIS. 


cations^  are  those  of  Chadwick,  of  Goodell  of  Philadelphia,  and  of  Dag- 
get  of  Buffalo.  The  great  objection  to  Chadwick's  table  is  the  lack  of 
mechanism  for  obtaining  the  lateral  inclination.  It  should  be  remem- 
bered that  the  office  lounge  or  sofa  is  simply  a  makeshift,  and  the  phy- 
sician will  find  that  it  rarely  requires  any  persuasion  to  induce  his  patient 
to  recline  on  his  table,  provided  she  be  assured  that  no  unnecessary  expo- 
sure is  entailed. 

JSText  in  importance  is  the  securing  of  the  proper  position,  as  will  be 
noted  farther  on,  and  preliminary  to  the  position  is  the  loosening  of  the 
corsets  and  clothing,  so  that  the  abdomen  may  be  readily  accessible  to 

Fig.  114. 


Thomas's  Table  as  modified  by  Dr.  B.  H.  Dagget  (for  Sims's  position). 


the  examining  hand  and  free  play  of  the  abdominal  muscles  secured. 
The  advantage  of  a  good  light  is  of  course  obvious. 

The  local  examination  should  be  made  in  stages,  so  to  speak,  and 
these  I  shall  describe  separately  and  in  succession  according  to  the  fol- 
lowing scheme : 

A.  The  Dorsal  Position  :  1.  Inspection  ;  2.  Digital  examination  ; 
3.  Bimanual  examination ;  4.  Instrumental  examination ;  5.  Rectal 
examination  and  conjoined  rectal ;  6.  Abdominal  percussion,  ausculta- 
tion, mensuration,  and  palpation. 

B.  The  Left  Lateral  or  Sims's  Position  :  1 .  Digital  examina- 
tion ;  2.  Instrumental  examination. 

^  A.  G.  Armstrong  of  Ashtabula,  O.,  makes  a  table  on  the  same  general  principles, 
but  rather  too  complicated. 


riFYsK  .11.  .sjt.ys.  297 

C.  Tin:  Gkni'-Pkctouai-  Position. 

I>.    Tin:  Ki:i:<T  Position. 

Tin:  l)i>i;-Ai,  l'o>ii'ioN. —  It  i>  tium  tlii-  |M»iti"»ii  tli:it  tlic  <'\;iiiiiin'r 
fVtM|iu'iitlv  secures  his  most  iiiiportaiit  inf'oiMiiatioii,  and  the  exainiii:itii)ii, 
tlieivtore,  should  he  ina«U'  with  tlie  ureatest  po.ssihle  eare,  since  tlie  tacts 
not<Hl  will  vary  pari  j)(i.s.sh  with  the  <leliheratoness  ased  and  the  e<lii- 
catioii  ot"  the  exainini!i<;  lin;j:er.  The  patient  shonld  lie  on  her  i>aek, 
her  hea<l  resting  on  a  low  hard  pillow,  her  nates  at  the  very  edjre  ot* 
the  taltic,  her  thiuhs  gently  (lexed  on  tlie  pelvis,  her  feet  resting  in  the 
I'oot-snpports.  She  should  he  covere<l  by  a  sheet,  and  this  may  Ix? 
raised  or  suitably  arrantjed  ibr  tlie  purposes  of  the  fii'st  ste|) — inspec- 
tion. This  inchules  the  abdomen,  vulva,  perineum,  and  anus.  As  a 
routine  measure  it  is  not  necessary,  at  the  outset,  to  inspect  the  alxlomen. 
Only  where  there  exists  obvious  abdominal  enlargement  is  it  advisable 
to  Ix'gin  with  inspection  of  this  portion  of  the  body.  Usually  we  await 
the  result  of  the  digital  examination,  including  the  bimanual,  before 
resorting  to  this  measure,  for  in  the  large  proportion  of  cases  it  is 
unnecessary'.  Should  its  necessity  be  apparent,  then,  in  connection 
with  inspection  of  the  abdomen,  we  must  frequently  resort  to  ausculta- 
tion and  percussion,  so  that  it  will  be  more  convenient  to  speak  of  this 
measure  later  in  connection  with  the  other  two. 

Inspection  of  the  external  genitals  should,  at  the  first  examination, 
never  be  neglected.  Much  valuable  information  may  thereby  be 
obtained,  aside  from  the  necessity  of  the  physician  protecting  himself 
against  the  transmission  of  pediculi  or,  above  all,  specific  disease.  The 
hair  surmounting  the  mons  Veneris,  therefore,  should  be  looked  at, 
and  suspicious  sores  sought  for  in  every  case,  no  matter  what  the  s<x-ial 
condition  of  our  patient,  before  resorting  to  any  further  examination. 
Erythema,  eruptions,  the  evidence  of  scratching,  the  state  of  the  labia  as 
regards  swelling  or  abnormal  development,  are  points  which  are  quickly 
taken  in  at  a  glance,  and  suggest  irritating  discharge,  disease  of  the 
vulva  or  its  glands,  the  habit  of  self-abuse.  The  labia  are  now  to  he 
gently  separated  and  the  vestibule  investigated.  The  points  to  be 
noted  are,  successively,  the  clitoris  and  its  development ;  the  meatus 
uriuarius — in  regard  to  eversion  of  the  mucous  membrane  of  the 
urethra,  the  presence  of  discharge  or  of  caruncles;  the  hymen — whether 
intact,  distended,  or  torn  ;  the  amount  of  discharge  present  in  the  vesti- 
bule— its  color  and  consistency  ;  the  traces  which  parturition  almost 
invariably  leaves  at  the  posterior  commissure.  It  is  advisable  at  this 
point  to  request  the  patient  to  strain  or  bear  down,  and  to  note  the 
effect  which  this  act  has  on  the  perineum  and  anterior  or  posterior 
vaginal  wall,  for  thereby  we  are  informed  in  regard  to  the  tone  of  the 
]x'lvic  floor,  as  well  as  in  regard  to  the  existence  of  sagging  of  the 
vaginal  walls.     The  finger — preferably  the  left  index,  although  it  is 


298  GYNECOLOGICAL  DLiGNOSLS. 

of  great  advantage  to  train  ourselves  to  use  the  right  index  as  well — 
should  now  be  introduced  into  the  vagina ;  and  this  brings  me  to  the 
consideration  of  what  may  be  learned  from  the  digital  vaginal  exami- 
nation. 

Whilst  inspection  may  be  performed  sitting,  or,  preferably,  standing 
a  little  to  the  right  of  the  patient,  the  digital  examination  can  only 
properly  be  made  when  standing  between  the  patient's  everted  thighs. 
The  finger,  previously  anointed  with  oil — or,  what  serves  the  same  pur- 
pose and  is  more  cleanly,  with  soap — should  ever  be  introduced  from 
below  upward,  due  care  being  taken  not  to  carry  along  with  it  any 
of  the  hair  which  frequently  .profusely  covers  the  organs  of  generation. 
It  should  be  introduced  carefully,  so  as  to  give  rise  to  no  unnecessary 
pain,  and  should  note  in  succession  the  elasticity  of  the  hymen  if  it  still 
exist,  the  presence  of  spasm,  the  temperature  of  the  vagina,  the  state 
of  its  walls  whether  rough  or  smooth,  the  direction  of  the  canal,  the 
elasticity  or  tone  of  its  walls.  It  may  be  well  to  state  that  my  remarks 
at  this  point  concern  more  particularly  the  married,  for  in  the  unmar- 
ried a  vaginal  examination  should,  in  general,  be  preceded  by  the 
rectal,  as  will  be  noted  under  that  heading.  The  finger  has  now 
reached  the  upper  vagina,  and  more  space  for  investigation  may  be 
gained  by  gently  but  firmly  depressing  the  perineum.  The  cervix  is 
next  to  be  examined  in  regard  to  shape,  density,  size,  direction,  length, 
and  sensitiveness. 

The  majority  of  these  factors  materially  assist  us  in  diagnosis.  The 
shape,  for  instance,  will  often  at  once  suggest  a  cause  of  sterility,  as 
where  this  is  conical.  By  the  density  we  differentiate  the  softening  en 
masse — gravidity,  the  softening  around  the  external  os — erosion,  the 
hard  fibrous  feel  suggestive  of  advanced  hyperplasia  or  of  scirrhous 
cancer,  the  large  heavy  cervix  accompanying  subinvolution.  By  the 
direction  we  gain  an  idea  of  the  probable  position  of  the  corpus  uteri, 
which  our  next  method  of  examination  is  needed  to  confirm.  The 
position  and  condition  of  the  external  os  are  to  be  carefully  noted, 
especially  as  to  whether  it  be  lacerated  or  not,  and,  in  the  first  instance, 
as  to  whether  the  rent  be  unilateral  or  bilateral,  the  depth  to  which  the 
rent  extends,  and  the  sensitiveness  at  the  angles  of  the  rent ;  and,  in 
the  latter  instance,  as  to  the  shape  of  the  os,  parous  or  not,  and  as  to 
the  patency  in  degree  and  extent.  This  is  all  the  information  which 
the  unaided  internal  finger  can  to  advantage  glean.  It  may,  of  course, 
pass  to  the  vaginal  vault,  but  any  exact  determination  of  the  conditions 
there  present  and  of  the  organs  adjacent  to  it  must  await  our  next  step 
— the  bimanual  or  conjoined  examination. 

It  is  only  in  comparatively  recent  times  that  the  necessity  of  the  biman- 
ual examination  has  been  recognized  and  insisted  upon.  Now-a-days  no 
examination   is  complete,  or  even  approximately  correct,  unless  this 


rilYsicAL  sKiys.  2119 

iiU'tlmd  liiis  Im'cii  svsl('iii:ili<;illy  iixd.  Ivxccption.illv  only,  as  wIktc 
there  is  jireat  jidipo.-e  <le\  (Inimiciil  of  (lie  .-ilMlniiiiiial  walls,  iiitlariiiiia- 
torv  disease,  or  >iie|i  li\  |)ei:i'>|li<>ia  on  the  pail  of  oiir  |»atient  as  to 
interliTe  with  snllieient  de|)ression  of  the  ahiloineii,  is  it  inijiossihle 
to  resort  to  this  inaiio-uvre  ;  and  in  siu-h  <'ases,  in  order  to  complete  onr 
(lia<;iiosis,  it  iiia\  i>e  necessary  to  resoil  to  ana'sthesia.  Otherwise,  how- 
ever, if  the  patient  ocenpies  the  proper  position,  as  already  descrihed, 
and  the  exaniinei"  makes  uciitle  hut  steady  |»i-essnre  in  the  ri^lit  direc- 
tion, the  contents  of  tJM'  pelvis  and  the  tnpDm-njihy  ol"  it>  coniaiiied 
oi-uans  mav  he  acciii'ately  studied.  To  perform  the  hiinanual,  the 
examiner  stands  hetween  the  |)atient's  everted  thi<ihs,  the  Madder 
havino-,  if  neeessarv,  heen  previously  emptied  ;  |>laces  his  hand,  pre- 
lerahlv  the  riuht,  on  the  alxhimeii  ahout  midway  hetween  the  nmhilieus 
and  the  puhes,  and  with  the  tint-ers  maUes  pi-essure  in  the  direction  of 
the  axis  of  the  pelvic  inlet,  eounsolliiiij;  his  patient  to  hreathe  quietly 
and  to  relax  hei-  ahdominal  nniseles  as  nuieh  as  is  in  her  })ower.  His 
external  hand  will  thus  rea<lily  eome  upon  the  fundus  of  the  uterus,  if 
this  organ  be  in  fair  position  or  anteriorly  disj)lace<I,  or  else  will  meet 
the  internal  fiULi'er,  which  should  he  restinu"  in  the  anterior  cul-de-sae. 
This  cul-de-sae  should  now  be  exj)lorcd  for  evidence  of  thickening- 
in  the  vagi  no- vesical  space,  for  the  presence  of  a  body  which  further 
examination  nuist  distinguish  as  the  fundus  uteri,  or  tumor,  or,  excep- 
tionally, an  anteriorly  displaced  ovary.  If  this  body  be  continuous 
with  the  cervix,  if  motion  imparted  to  it  be  communicated  t(»  the 
cervix,  if  further  ex])loration  posteriorly  to  it  reveal  no  other  b<»dv, 
we  are  assured  that  it  is  the  fundus.  If,  on  the  other  hand,  we  find 
another  body  posterior  to  it,  in  connection  or  separate,  we  immediately 
think  of  a  tumor  in  the  anterior  fundal  wall,  loosely  connected  with  or 
independent  of  it.  Then  it  may  be  necessary,  as  noted  farther  on,  to 
resort  to  the  sound  for  differential  diagnosis.  If  this  body,  however, 
be  small  and  sensitive,  the  ovary,  out  of  position,  suggests  itself.  The 
finger  in  the  anterior  cul-de-sae  should  further  seek  for  an  angle 
of  flexion  formed  at  the  junction  of  the  cer\'ix  and  body  of  the 
uterus,  and  should  note  the  elasticity  of  the  cul-de-sac  and  its  dejith. 
The  internal  finger  should  now  pass  successively  to  the  left  and  right 
lateral  culs-de-sac,  the  external  hand  bringing  the  organs  w  Inch  lie  in 
these  regions  within  reach.  These  regions  are  to  be  explored  esjiecially 
in  regard  to  density,  thickening,  or  fluetuation,  suggesting  rcH-ent  or 
chronic  inflammatory  processes,  or  alterations,  inflammatory  or  not,  in 
the  ovaries,  tubes,  or  layers  of  the  broad  ligaments;  and  now,  too,  if 
the  patient  be  spare  or  there  be  sufHcient  relaxation  of  the  abdominal 
muscles,  the  ovaries  may  be  felt  if  in  their  normal  position,  and  they 
are  distinguished  by  their  size,  sha]>e,  and  by  the  peculiar  sickening 
pain  which  pressure  almost  always  will  evoke.     If  the  uterus  be  later- 


300  GYNECOLOGICAL  DIAGNOSIS. 

ally  displaced,  the  fact  may  be  detected  whilst  these  lateral  regions  are 
being  explored.  The  finger  should  now  pass  to  the  posterior  cul-de- 
sac,  and,  under  favorable  conditions,  the  abdominal  walls  may  be 
sufficiently  depressed  to  allow  the  external  hand  to  meet  it  there. 
The  elasticity  of  this  cul-de-sac  should  also  be  tested,  evidence  of 
acute  or  chronic  exudation  sought  for,  the  posterior  ligaments  of  the 
uterus  tested  for  thickening,  the  depth  of  the  cul-de-sac  noted,  and, 
even  as  in  the  examination  of  the  anterior  cul-de-sac,  the  nature  of 
any  body  differentiated  as  the  fundus,  or  tumor  connected  with  or 
independent  of  the  fundus,  and  an  angle  of  flexion  is  also  to  be  sought 
for.  Here,  too,  the  sound  may  be  necessary  to  make  the  diflPerential 
diagnosis,  although  ordinarily  the  conjoined  fingers  will  suffice.  Doug- 
las's cul-de-sac  is  also  a  favorite  resting-place  for  prolapsed  ovaries,  and, 
as  before,  these  may  ordinarily  be  distinguished  by  their  size,  shape, 
and  sensitiveness.  Scybala  in  the  rectum  can  only  be  mistaken  for 
ovaries  by  the  careless  examiner.  The  next  step  is  to  test  the  mobility 
of  the  uterus,  to  estimate  its  size  and  its  shape,  and  the  relation  as  to 
direction  this  body  holds  to  the  cervix.  The  mobility  is  ascertained 
by  placing  the  internal  finger  on  the  cervix  and  pushing  this  in  various 
directions,  or,  if  the  uterus  be  not  so  displaced  backward  as  to  render 
the  step  impossible,  the  external  hand  may  grasp  the  fundus  and  tilt  it 
backward  or  forward  or  laterally.  At  the  same  time  the  shape  and 
density  of  the  organ  are  estimated,  and  any  unevenness  of  its  walls 
noted.  When  movement  is  imparted  to  the  uterus,  the  examiner  is  to 
note  if  pain  is  thereby  given  to  the  patient,  and  as  to  how  much  the 
sphere  of  mobility  is  impeded  in  one  or  another  direction  according  to 
the  conditions  present  which  interfere  with  what  his  experience  teaches 
him  is  the  usual  range  of  motion. 

It  should  never  be  forgotten,  in  estimating  the  probable  relation 
existing  between  symptoms  complained  of  and  uterine  position,  that 
there  is  absolutely  no  fixed  standard  whereby  the  uterus  may  be  judged 
to  be  in  or  out  of  position.  In  regard  to  "  the  normal  position  of  the 
uterus  "  every  woman  is  a  law  unto  herself.  The  uterus  has  a  range 
of  normal  positions,  and  this  range  will  vary  in  each  woman  according, 
on  the  one  hand,  to  the  symmetry  of  her  pelvis,  and,  on  the  other  hand, 
to  the  length  of  the  ligaments  which  nature  has  supplied  to  the  organ 
to  act  as  checks  against  its  assuming  a  position  which  will — indeed, 
must — evoke  symptoms.  And  in  this  word  "  symptoms "  we  strike 
the  key-note  of  diagnosis  of  abnormal  uterine  position.  Obviously, 
the  uterus  may  in  one  woman  lie,  for  instance,  farther  fonvard  than 
in  another  without  giving  rise  to  symptoms  from  the  side  of  the  blad- 
der ;  and  this  for  the  reason  that  her  pelvis  is  more  capacious,  or  her 
bladder  less  intolerant  of  interference,  or  the  retro-uterine  ligaments 
longer ;  and  a  like  train  of  reasoning  will  apply  to  backward  or  down- 


nnsicAL  siass.  :>,()\ 

wanl  (li>|)l:ifcinciit.  It  is  not  -iiniciciil,  tlicirrorc,  iltr  tlic  cxariiiiK  r  to 
coiicliidr  tliat  tlu-  iitiTiis  is  ante-  or  rctrovcrtcd  in  a  particnlar  ("ase 
l»ccaii>('  one  or  aiiotlici'  aiitliority  states  dogmatical  I  v  tliat  the  like  |)<»si- 
tion  is  altnoiiiial  ;  Ixit  lie  nin~t  seek  iiirtlicr  as  to  whether  tlie  j»ositi(»n 
which  he  determines  will  account  for  the  synijitonis.  ll'  not,  the  j)o.si- 
tion  is  not  al)norniaI  i'uv  thi>  |i:nticiihir  woman.  I  wonid  Tnrther  hiv 
stress  on  the  fact  that,  ordinarily,  the  himamial  examination  alone  will 
tell  n<  snllicient  in  re<iard  to  the  jxtsition  of"  tiie  nterns  and  its  mohilitv 
to  render  rei-onrse  to  instrnmental  means  unneccssarv. 

Closely  eoiineeted  with  the  himanual  are  other  methods  of"  conjoined 
inanipid;ition,  sueh  as  vesieu-reetal,  reeto-abdominal,  vajri no- rectal.  The 
]»in-|)(»sc's  of  these  manipidations,  their  indications,  and  the  information 
to  be  thus  derived  will  find  an  aj)propriate  plaee  under  the  next  head- 
in<>-  and   in  eonneetion   with   it. 

Rcdal  Examination. — This  method  (tf  examination  is  repugnant 
alike  to  the  physieian  and  the  patient.  I  eannot,  as  some  do,  consider 
it  necessary  as  a  routine  measure.  The  information  to  l)e  thus  obtained 
in  retiard  to  the  uterus  and  its  adnexa  is  of  limited  nature,  and  never 
so  thorouo-h  as  that  yielded  by  careful  bimanual  examination  where  the 
conditions  are  favorable.  Except,  therefore,  where  the  rational  history 
suggests  rectal  disease,  or  \vhere  the  bimanual  is  for  one  or  another 
reason  incom})lete  or  unsatisfactory,  I  would  limit  this  examination  in 
general  to  cases  where  congenital  or  acquired  imperfections  or  obstruc- 
tions of  the  genital  canal  forbid  the  methods  of  examination  alreadv 
detailed,  and  to  virgins  in  order  to  acquire  information  which  might 
justify  us  in  rupturing  the  hymen  for  purposes  of  more  exact  diagnosis. 
Although,  however,  I  restrict  the  necessity  of  a  rectal  examination 
within  these  general  limitations,  I  would  note  here  that  not  infre- 
quently obscure  symptoms,  not  explainable  from  the  side  of  the  uterus 
and  its  adjuncts,  will  be  found  to  depend  on  such,  in  aj^pearance,  insig- 
nificant lesions  as  small  rectal  ulcer  or  anal  fissure,  even  though  these 
symptoms  do  not,  in  the  lea.st,  suggest  the  likelihood  of  rectal  disorder. 
In  order  to  properly  make  a  rectal  examination  it  is  essential  that  the 
rectum  should  have  been  evacuatc^l  beforehand.  It  will  hence  be  often 
necessary  to  postpone  such  an  examination  until  the  ])atient's  second 
visit,  that  she  may  prepare  herself  for  it  by  an  enema.  The  index 
finger,  gently  insinuated  through  the  sphincter  ani,  will  readily  detect 
any  foreign  growth  or  stricture  of  the  canal,  and  if  the  uterus  be  in  fair 
position  the  cervix  may  be  felt  pressing  against  the  posterior  vaginal  wall. 
The  posterior  limits  of  Douglas's  cul-de-sac  may  be  investigated,  as 
well  as  its  contents.  Xow,  by  resorting  to  abdomi no-rectal  examina- 
tion the  pelvic  organs  are  depressed  nearer  to  the  rectal  finger,  and  the 
posterior  surface  of  the  uterus  may  be  paljiated,  as  well  as  frequently 
the  ovaries  in  normal  position,  and  exceptionally  the  broad  ligaments. 


302  GYNECOLOGICAL  DIAGNOSIS. 

This  last  condition  may  be  better  satisfied  by  resorting  to  vagino-rectal 
examination,  whereby  a  double  tenaculnm  fixed  in  the  cervix  causes  an 
artificial  prolapse  of  the  uterus,  and  thus  approximates  its  lateral  sur- 
faces with  the  ligaments  to  the  rectal  finger.  AYith  the  finger  in  the 
rectum  an  excellent  opportunity^  is  also  offered  for  investigating  the 
integrit}^  of  the  perineal  body,  to  be  accomplished  either  through 
inserting  the  thumb  of  the  same  hand  into  the  vagina,  or  else,  as  is 
less  awkward,  the  index  of  the  other  hand. 

A  further  conjoined  method  of  rectal  examination,  the  vesico-rectal, 
is  of  special  utility  in  those  cases  where  there  is  possible  absence  of  the 
uterus,  and  Avhere  inversion  of  this  organ  needs  to  be  carefully  differ- 
entiated. Here  it  is  better  practice  to  introduce  a  sound  within  the 
bladder  rather  than  the  finger,  for  thus  we  obtain  as  exact  information 
without  risking  injury  to  the  urethra  or  vesical  neck.  AVe  may  also 
paljjate  the  anterior  surface  of  the  uterus  by  means  of  the  finger  in  the 
bladder,  although  the  vagino-abdominal  method,  assisted,  if  need  be, 
by  an  anaesthetic,  is  much  to  be  preferred.  Finally,  I  would  allude 
here  to  Simon's  method  of  rectal  examination  by  means  of  the  entire  hand. 
This  method  has  never  become  popular,  and  I  question  if  to-day  it  is 
considered  a  justifiable  procedure  from  a  gynecological  standpoint.  The 
method  requires  aneesthesia,  and,  unless  the  examiner's  hand  be  smaller 
than  the  average,  the  injuiy  done  to  the  patient  is  likely  to  be  greater 
than  any  possible  good  which  might  result  from  the  information  thus 
obtained.  I  believe  that  through  the  methods  of  examination  which  I 
have  already  described  a  diagnosis  may  be  reached,  if  one  is  at  all  pos- 
sible, without  resorting  to  Simon's  procedure,  and  I  therefore  simply 
mention  rectal  exploration  by  the  entire  hand  in  order  to  condemn  it. 

I  have  now  noted  in  succession  the  various  methods  of  digital  exami- 
nation appropriate  to  the  dorsal  position,  and  have  stated  the  general 
information  to  be  thence  derived.  In  the  natural  order  of  examination 
there  are  instrumental  means  of  diagnosis  which  will  be  resorted  to  in 
this  position  before  the  patient  assumes  the  left-lateral.  I  therefore 
deem  it  better  to  describe  them  here,  rather  than  in  connection  with 
the  description  of  more  special  instrumental  measures. 

The  instruments  of  particular  utility  in  the  dorsal  position  are — 1, 
the  sound  ;  2,  cylindrical  and  plurivalve  specula. 

T}\e  Sound. — The  best  form  of  this  instrument  is  that  devised  by 
Simpson.  It  is  sufficiently  flexible  to  allow  of  its  being  bent  by  the 
hand  to  any  desired  curve,  and  yet  not  so  much  so  as  to  bend  on  itself 
when  it  comes  in  contact  with  a  foreign  body  or  is  insinuated  into  a 
fold  of  the  cervical  mucous  membrane.  The  guiding  hand  is  therefore 
ever  conscious  of  the  location  of  the  point  of  the  sound.  A  further 
advantage  is  the  knob  marking  the  depth  of  the  normal  uterus, 
whereby  the  finger,  along  which  the  instrument  should  he  passed,  is 


I'llYSK'AL   SIGNS.  303 

cmistMiitK'  iiit'oniu'il  nf  ilic  prou'i'c.-s  tlic  mhiikI  is  iiiakiiij:-.  TIm'  tliick- 
ness  of  this  iiistrunit'iit  is  only  a  disatlvaiitatic  in  tliosc  cases  where 
tliere  exists  sharp  Hexioii  or  (•t)ii<;eiiital  »»r  aei|iiii"e<l  stenosis  of  the  cer- 
vical I'aiial,  iiiHler  which  coiKlitioiis,  as  will  he  noted  in  its  |)roj)er  j)hi<"e, 
the  proix'  is  to  he  used. 

TIu'  judicious  use  of  the  sound  may  revi'al  very  iiuportant  inlornia- 
tion.  Its  injudicious  use  may  result  in  serious  damaj^c  to  the  ])atient. 
The  contraindications  should  therefore  ever  be  borne  in  mind,  and 
these  are  two  in  munl)er — ]»reu'nancv,  peritoneal  or  cellular  iuHainma- 
tion.      These  conditions   having-   been   strictly  eliminated,  the  sound, 

Fig.  115. 
GcoT/£MANN&Co. 

Simpson's  Souud.  grariuatcd. 

used  with  care,  can  scarcely  inflict  damasje.  Whilst  I  cannot  ^o  so 
far  as  to  say  that  no  diaiiiiosis  is  complete  nnless  the  sound  has  been 
used,  I  advise  its  systematic  employment  in  every  case  where  no  con- 
traindication exists.  The  instrument  may,  of  course,  be  introduced 
with  the  patient  in  the  semi-prone  as  well  as  in  the  dorsal  position. 
This  is  largely  a  matter  of  individual  choice  or  of  habit.  Personally, 
I  favor  the  introduction  in  the  dorsal  position,  because  just  previous  to 
its  use  we  may  ordinarily  assure  ourselves  bimanually  of  the  position 
of  the  uterus,  and  are  therefore  better  able  to  formulate  the  curve 
which  the  instrument  must  have  and  the  direction  it  will  have  to  take. 
The  sound,  then,  held  lig'htly  Ijctween  the  forefinger  and  the  thuml)  of 
the  right  hand,  is  to  be  introduced  along  the  index  of  the  left  hand  as 
a  guide  until  it  reaches  the  external  os ;  passing  through  this  along 
the  canal  to  the  internal  os,  the  handle  is  to  be  depressed,  elevated,  or 
rotated  according  to  the  probable  site  of  the  fundus  as  deduced  from 
the  bimanual.  If  during  its  progress  the  point  catches  in  a  fold  of 
the  mucous  membrane,  the  instrument  is  to  be  \vithdrawn  and  again 
introduced.  Absolutely  no  force  is  to  be  used,  the  instrument  being 
allowed,  as  it  were,  to  find  its  0'\vn  way.  The  information  to  be 
derived  from  the  use  of  the  sound  is — the  patency  and  size  of  the 
external  os  and  of  the  cervical  canal,  and  the  state  as  regards  smooth- 
ness or  roughness  of  its  lining  membrane;  the  sensitiveness  and  the 
patency  of  the  internal  os  ;  the  degree  of  flexion  ;  the  depth  of  the 
uterus ;  the  sensitiveness  of  the  endometrium  ;  the  exact  position  of 
the  fundus  ;  and  the  general  direction  of  the  uterine  axis.  It  is  evi- 
dent, therefore,  that,  aside  from  giving  us  infitrmation  which  is  other- 
wise not  obtainal)le,  the  S(jund   will  vcrifv  nuicii   which  the  biuiaiuial 


304  GYNECOLOGICAL  DIAGNOSIS. 

has  taught  us,  and  also,  where  the  bimanual  has  been  impossible  or 
unsatisfactory,  supplies  the  facts  which  we  would  otherwise  lack.  The 
value  of  the  instrument  for  purposes  of  differential  diagnosis  is  also 
apparent ;  as,  for  instance,  where  the  bimanual  has  revealed  a  tumor  in 
front  of  or  behind  the  uterus  the  sound  will  tell  us  which  is  the  corpus 
uteri  and  Avhich  the  tumor.  As  for  the  use  of  this  instrument  as  a 
uterine  redressor  or  to  test  the  mobility  of  the  uterus,  I  most  unqual- 
ifiedly condemn  it.  I  know  that  in  skilful  hands  it  mav  be  made  to 
subserve  these  purposes  without  necessarily  inflicting  injurv  ;  but, 
knowing  also  that  damage  may  be  done  through  the  purchase  which 
the  instrument  necessarily  takes  at  the  fundus,  I  reject  the  sound  and 
uniformly  use  one  of  the  special  instruments  constructed  as  redressors, 
and  which  take  their  point  cVappui  at  the  external  os.  It  will  be 
noticed  that  I  have  not  referred  to  the  introduction  of  the  sound 
through  the  cylindrical  or  the  plurivalve  specula.  I  do  not  favor 
such  a  procedure,  because  I  know  that  the  careful  introduction  of  the 
instrument  is  best  assured  when  the  finger  in  the  vagina  acts  as  a 
guide,  and  also  because  there  are  positions  of  the  uterus  where  these 
specula  seriously  interfere  with  the  passage  of  the  instrument,  occa- 
sionally prevent  it  entirely. 

The  Cylindrical  and  Plurivalve  (■specula. — The  uses  of  the  speculum 
in  the  dorsal  position  are  xery  limited.  Indeed,  I  question  if  gynecology 
would  ever  have  obtained  the  rank  it  holds  had  not  the  genius  of  Sims 
rendered  evident  the  immense  advantage  offered  by  the  specular  exami- 
nation made  in  the  position  ordinarily  known  by  his  name,  and  which 
I  shall  describe  farther  on.  And  the  truth  of  this  assertion  is  borne 
out  by  the  fact  that  skill  in  the  diagnosis  and  in  the  treatment  of  uterine 
disease,  properly  so  called,  is  most  marked  in  those  countries  where  the 
dorsal  position  is  made  to  subserve  the  purposes  of  the  digital  exami- 
nation, and  the  left-lateral  the  specular.  Through  both  the  cylindrical 
and  the  plurivalve  specula  the  field  of  vision  is  limited,  the  play  of 
whatever  instrument  is  necessary  for  diagnosis  and  treatment  is  nar- 
rowed and  often  negatived,  and  certain  lesions  of  the  cervix  may  be 
effaced  or  obscured  which  it  is  of  paramount  importance  to  detect. 
I  need  only  instance  the  fact  tliat  laceration  of  the  cervix  is  mistaken 
for  ulceration  by  those  examiners  who  habitually  use  these  specula  and 
the  dorsal  position.  Hence,  personally,  I  recommend  the  use  of  the 
speculum  in  the  dorsal  position  solely  for  the  purpose  of  making 
applications  to  the  vagina  or  external  os.  For  purposes  of  diag- 
nosis I  do  not  favor  it  at  all,  because  the  limited  information  thus 
obtainable  may  be  secured  to  better  advantage  in  the  lateral  position, 
and,  at  the  same  time,  facts  may  be  ascertained  and  treatment  be 
employed  which  cannot  be  in  the  dorsal  position.  I  would  note  here, 
hf)wever,  that  occasionally,  as  where  the  rational  history  suggests  abun- 


J'lIYSlCAL  SfGNS. 


305 


<l;iiit  IciicDrrlid'M,  it  is  :i(lvi>al)lc  to  iiitroiliicc  the  spcciiliiiii  hofore  the 
tiiiiicr,  and  then  the  cvliutlriral  spcciiliiiii  will  sullicc  to  .sliow  us  the 
source  of  the  (iiscliaruv. 

Cyliiulrieal  spa-ula  arc  constructed  preferahly  ol"  ;i:lass  or  hard  rub- 
ber.    The  Fcro;ussou  uiay  l>c  takcu  as  a  type,  and  is  to  he  obtained   in 

Fig.  110. 


Fergusson's  Speculum, 

nests  of  various  sizes.  This  speculum  is  readily  introduced,  previously 
anointed  with  oil  or  soap,  by  depressing  the  perineum  ^vith  its  point 
and  gently  insinuating  it  up  to  the  cervix.  If  the  vaginal  walls  be 
not  specially  lax,  and  if  the  cervix  be  in  fair  position,  there  is  but 
little  difficultv  in  eno-aging:  the  external  os  in  the  field  of  vision. 
Oftener  than  not,  however,  the  speculum  must  be  withdrawn  and 
reintroduced  a  number  of  times  before  this  can  be  accomplished,  and 
where  the  cervix  lies  far  backward  it  requires  considerable  ingenuity 
and  patience  to  see  it  at  all. 

Valvular  specula  are  constructed  of  either  two,  three,  or  four  blades. 


Fig. 117. 


A'"- 


Brewer's  Speculum. 

Many  have  been  invented,  and  each  doubtless  remains  in  favor  with  its 
inventor,  although,  for  reasons  already  sufficiently  state<l,  they  are  one 
and  all  inadequate  for  purposes  of  accurate  diagnosis  and  treatment 
according  to  the  requirements  of  modern  gynecology.  It  is  out  of  tlie 
question  to  attempt  a  description  of  the  many  forms  here.  I  content 
Vol.  I.— 20 


306 


GYNECOLOGICAL  DIAGNOSIS. 


Notts's  Speculum. 


myself  with  mentioning,  as  typical  of  the  bivalve,  Brewer's  speculum ; 

of  the  trivalve,  Notts's ;  of  the 
Fig.  118.  quadrivalve,  Meadows's.    These 

specula  are  introduced  closed  and 
afterward  expanded,  and  may  be 
used  in  the  lateral  as  well  as  in 
the  dorsal  position.  It  is  safe 
to  say,  however,  that  the  gyne- 
cologist wdio  has  once  accustomed 
himself  to  Sims's  speculum  will 
never  desert  it  for  any  form  of 
plurivalve ;  and  it  is  equally  true 
that  the  general  practitioner, 
desirous  of  doing  something 
more  for  his  patients  than  apply- 
ing the  time-honored,  but  to-day 
almost  neglected,  stick  of  lunar 
caustic  to  the  cervix,  must  learn  how  to  use  Sims's  speculum  and  the 
left-lateral  position.  And  therefore  it  is  why  I  do  not  deem  it  neces- 
sary to  sj)end  time  and  waste  space  on  a  description  of  the  many  forms 
of  multivalve  specula  and  their  manner  of  introduction.  A  science 
should  be  practised  correctly  or  not  at  all,  and  surely  no  gynecologist 
w^ill  to-day  claim  that  he  is  able,  through  any  form  of  multivalve 
whatever,  to  accomplish  what  he  can  through  a  Sims.  And,  whilst  my 
remarks  here  are  limited  to  diagnosis,  how  much  more  forcible  do  they 
become  when  applied  to  the  treatment  of  intra-uterine  disease  !  Both 
exact  methods  of  diagnosis  and  correct  methods  of  treatment  are  only 
possible  to  a  limited  degree  through  tubular  and  plurivalve  specula. 
Aside  from  the  exceptions  already  noted  (applications  to  the  vagina 
and  cervix),  I  see  no  further  use  for  these  instruments,  and  believe 
that  the  time  has  come  when  they  should  be  weeded  out  of  the  already 
too  cumbersome  gynecological  armamentarium ;  and  my  belief  is  the 
firmer  because  of  the  fact,  to  be  noted  farther  on,  that  the  oft-repeated 
objections  to  Sims's  speculum  are  really  not  tenable. 

Since  the  points  to  be  noted  through  the  speculum  appear  to  better 
advantage  through  Sims's  than  any  other,  their  description  is  deferred 
for  a  time,  and  it  remains  now  to  consider  the  final  diagnostic  measures 
which  properly  belong  to  the  dorsal  position. 

Examination  of  the  Abdomen  :  Inspection,  Mensuration,  Aus- 
Gultation,  Percussion,  Palpation. — In  inspection  of  the  abdomen  we 
are  to  look  for  the  whitish  lines,  lineje  albicantes,  the  result  of  the  rup- 
ture of  muscular  fibrils  and  evidence  of  distension  of  the  abdominal 
walls  ;  we  are  to  note  the  shape,  whether  flat  on  the  surface  and  bulg- 
ing in  the  flanks,  whether  round  or  spherical,  suggesting  in  turn  ascites, 


PHYSICAL  SIGNS.  307 

<>vai"i:in  <'yst,  or  j^ravidity  ;  \vc  arc  to  seek  luovcnioiits  of  the  surf'atx*, 
su;;ji;e.stin<;;  arterial  pulsation,  Inetal  motion,  pa-ssage  of"  flatus  through 
the  intestines;  projection  at  any  one  p(jrtif»n,  suggesting  hernia,  Hl)roi(ls. 
These  are  possibilities  which  eitiier  our  previous  examination  or  that 
whieh  is  to  foMow  will  verily. 

Mensuration  is  more  [jarticularly  of  service  to  the  obstetrician.  Still, 
in  eonneetion  with  the  growth  of  abdominal  tumors  the  gynecologist 
must  fre<iuently  have  recourse  to  this  measure.  The  measurements  oi' 
greatest  service  are  those  taken  at  the  level  of  the  umbilicus  and  from 
the  ensiform  cartilage  to  the  pubes.  We  are  thus  kept  informed  as  to 
the  rate  of  growth  of  tumors,  and  may  satisfactorily  check  their  dim- 
inution under  treatment  or  at  the  approach  of  the  menopause. 

Auscultation  and  percussion  are  similarly — especially  the  former — 
of  greater  utility  from  an  obstetrical  than  from  a  gynecological  stand- 
point. Xot  uncommonly,  however,  the  gynef.-ologist  is  called  upon  to 
make  a  differential  diagnosis  of  pregnancy  in  its  later  stages,  and  then, 
obviously,  the  obtaining  of  the  foetal  heart  through  auscultation  is  of 
essential  importance.  Succussion,  or  the  splashing  of  fluid  in  the  abdo- 
men on  change  of  position  of  the  patient,  is  thus  also  obtainable,  as 
well  as  the  bruits  suggestive  of  change  in  the  blood-vessels  or  pressure 
upon  them.  Percussion  is  one  of  our  most  valuable  means  of  obtain- 
inu;  information  in  regard  to  the  nature  of  abdominal  enlaro;ements. 
The  uniform  and  general  tympanitic  note,  characteristic  of  gaseoas  dis- 
tension of  the  intestines ;  the  dull  note  in  the  flanks  and  tympanitic  in 
the  epigastrium,  suggestive  of  ascites ;  the  local  dulness  accompanying 
local  tumor  or  distended  bladder ;  the  shading  off  of  the  dull  into  the 
tympanitic,  or  vice  versd,  suggestive  of  tumor  growing  from  above,  or 
the  reverse ;  the  sense  of  resistance  to  the  percussed  finger,  suggestive 
of  either  fluid,  semi-fluid,  or  solid  contents, — such,  in  outline,  are  the 
points  obtainable  through  percussion. 

Palpation  of  the  abdomen,  as  already  stated,  is  not  necessary-  as  a 
routine  measure  in  gynecological  practice ;  but  when  the  histori', 
appearance,  or  digital  examination  renders  probable  the  presence  of 
abdominal  enlargement,  then  this  measure  must  be  resorted  to ;  and  it 
is  essential  that  the  patient  should  be  properly  prepared  for  the  neces- 
sary' manipulation,  and  that  the  examiner  should  proceed  systematically 
and  with  gentleness.  The  bladder  having  been  emptied,  the  clothing 
loosened,  and  the  abdomen  exposed,  the  examiner  stands  on  the 
patient's  right,  and,  encouraging  her  to  relax  the  abdominal  muscles, 
depresses  with  the  tips  of  his  fingers,  gently  but  firmly,  the  various 
regions  of  the  abdomen.  Where,  from  excess  of  adipose  development 
or  h%-persesthesia  of  the  abdominal  walls,  manipulation  is  impossible  or 
unsatisfactory',  then,  should  the  necessity  of  palpation  be  obvious, 
recourse  must  be  had  to  anaesthesia,  when  a  tumor,  otherwise  undis- 


308  GYNECOLOGICAL  DIAGNOSIS. 

coverable,  may  be  revealed,  or  else  one  manifest,  but  of  uncertain  nature, 
may  disappear  (so-called  phantom  tumor).  The  facts  to  be  learned  from 
palpation  may  be  summarized  :  The  probable  abdominal  or  pelvic  ori- 
gin of  a  tumor ;  the  density  and  general  outline  of  such  tumor ;  its 
single  or  multiple  nature ;  its  fixation  or  mobility ;  its  size  and  depth 
below  the  surface ;  its  probable  connection  with  other  organs  ;  the  pres- 
ence of  fluid,  general  or  localized,  in  the  abdominal  cavity.  Thus,  then, 
we  differentiate  between  abdominal  and  pelvic  tumors  proper,  or  simple 
enlargement  of  abdominal  organs  ;  thus  we  recognize  a  movable  kidney, 
a  multi-  or  unilocular  ovarian  cyst,  subperitoneal  fibroids,  the  gravid 
uterus,  the  uterus  enlarged  by  cyst  or  new  growth  of  solid  or  semi-solid 
nature,  abscesses  within  the  abdominal  walls,  hernia,  aneurism  :  indeed, 
in  a  favorable  case,  the  skilled  examiner  may  often  so  thoroughly  pal- 
pate as  to  be  assured  in  turn  of  the  probable  gross  condition  of  every 
one  of  the  important  abdominal  organs.  It  is  out  of  place  to  do  more 
than  refer  here  to  the  value  of  abdominal  palpation  to  the  obstetrician 
in  determining  the  position  of  the  foetus  within  the  uterus,  the  existence 
of  multiple  gestation,  etc. 

The  Left-lateral  Position. — Thoroughness  and  ease  of  exami- 
nation in  this  position  will  depend  on  its  being  properly  and  exactly 
assumed.  The  position  aims  at  bringing  the  force  of  gravity  to  bear  on 
the  abdominal  and  pelvic  organs,  whereby  they  are  caused  to  sink  down- 
ward and  upward,  thus  tending  to  produce  a  vacuum  in  the  vagina, 
which  the  external  air,  on  separating  the  labia,  rushes  in  to  satisfy,  and 
thereby  balloons  out  the  vagina  and  the  vaginal  vault.  To  obtain  these 
conditions  at  their  maximum  the  thorax  must  be  the  lowest  point  and 
the  sacrum  the  highest  when  the  patient  is  lying  in  this  position.  Even 
as  in  the  dorsal  position,  and  still  more  essential,  the  patient's  clothr 
ing  must  be  loosened  from  around  the  waist  and  compression  of  the 
chest-walls  by  the  corset  removed.  The  steps  by  which  this  position 
may  be  assumed  are  as  follows  :  The  patient,  resting  on  her  left  natis* 
at  the  edge  of  the  examining-table  to  the  left  of  the  mid  line,  places 
her  left  arm  behind  her  and  lies  down  diagonally  across  the  table,  the 
left  cheek  on  the  pillow  and  the  left  thoracic  wall  against  the  mattress. 
She  has  thus  rolled  over  on  her  chest,  and  the  lowest  point  of  our  posi- 
tion has  been  obtained.  Next,  the  thighs  are  flexed  on  the  trunk,  the 
right  more  than  the  left,  so  that  the  right  knee  projects  considerably 
over  the  left,  and  the  legs  are  placed  at  a  right  angle  to  the  thighs.  The 
pelvis  has  now  been  elevated,  and  the  sacrum  is  the  highest  point  of 
the  position.  During  this  manoeuvre  the  nates  are  often  pushed  too  far 
up  on  the  table,  so  that,  as  a  further  step,  it  is  necessary  to  draw  them 
well  down  to  the  edge.  The  hands  may  now  grasp  the  lateral  edges 
of  the  table,  and  the  patient  is  in  position.  She  should  be  covered  by 
a  sheet,  which  is  tucked  around  the  superior  (right)  leg  and  thigh,  the 


I'll  y  sir  A/,  Slays. 


noo 


Icl't  It  l;'  and  tlii<;li  being  covcrcil  l)y  a  tttwcl,  tho  vulva,  jK-riiuMim,  and 
anus  aloiic  remaining"  cxixtscd.  '^|"'li('  tal)l('  slioidd  We  so  placed  that  the 
lijilit  niav  strike  slaiitiii<ily,  IVnni  lu-forc  backward,  on  these  parts.  If 
the  tabic  have  the  lateral  inclination  rcierre<l  to  in  the  remarks  on  this 
sul)jcct,  it  is  obvious  that  the  force  of  jfravity  may  still  further  be  called 
into  i)la\-  lt\'  utiii/.inii-  it.  This  inclination,  however,  whilst  a  decided 
ad\anta<i;e  if  the  examiner  have  no  assistant,  is  not  indispensable. 

Before  proceedino-  to  a  description  of  the  methods  of  examination  in 
tho  left-lateral  position,  it  seems  proper  to  consider  very  briefly  the 
objwtions  to  this  position   advanced,  in   |)articular,  by  ouv  transatlantic 

Ftg.  119. 


The  Left-lateral  Position  (after  Munde,  from  Hegar  and  Kaltenbach.) 

brethren.  These  objections  are  three  in  number :  1.  There  is  greater 
exposure  of  the  patient  than  in  the  dorsal  position.  2.  The  change  to 
this  position  from  the  dorsal  requires  extra  time  and  trouble.  3.  The 
use  of  the  left-lateral  position  necessitates  the  presence  of  an  assistant. 
The  first  objection  is  not  founded  on  fact,  and,  even  though  it  were 
true,  the  patient  would  not  object  to  greater  exposure  if  assured  that 
at  the  same  time  she  receives  greater  benefit.  The  truth  is,  that  in  the 
left-lateral  position,  the  patient  being  properly  arranged,  the  vulva, 
perineum,  and  anus  are  alone  exposed,  and  these  parts  it  is  essential 
to  expose  also  in  the  dorsal  position  in  order  to  introduce  a  tubular  or 
valvular  speculum.  The  second  objection — to  grant  for  a  moment  that 
it  is  worthy  of  serious  consideration — falls  to  the  ground  in  the  face  of 
the  assertion,  not  to  be  denied  to-day,  that  the  extra  trouble  simply 
leads  to  correct  diagnosis  and  effective  treatment.  The  third  objec- 
tion is,  in  a  measure,  valid.  It  is  simply  a  Avise  precaution  for  the 
physician,  when  able,  to  have  a  trained  assistant  present  to  assist  him 


310  GYNECOLOGICAL  DIAGNOSIS. 

in  arranging  his  patient  and  to  hold  the  specukim.  The  presence  of  a 
nurse  is  a  safeguard  against  blackmail,  and  equally  so  whether  the 
patient  be  examined  in  the  dorsal  or  the  left-lateral  position.  It  is  a 
great  convenience,  too,  to  have  some  one  at  hand  to  hold  the  Sims's 
speculum,  but  where  the  amount  of  practice  or  the  means  of  the 
physician  do  not  necessitate  or  allow  the  constant  presence  of  the 
trained  nurse,  I  can  affirm  that  he  may  intelligently  and  correctly  use 
this  instrument  alone,  if  he  but  possess  one  of  the  modified  forms 
which  will  be  described  farther  on.  I  believe,  indeed,  tliat  the  above 
objections  to  Sims's  instrument  and  position  are  simply,  in  part,  the 
outcome  of  ignorance  as  to  use  and  benefits  obtainable — in  part  of 
unwillingness  to  change  from  routine  and  time-honored  methods. 

Digital  Examination  in  the  Left-lateral  Position. — For  diagnosis  by 
means  of  the  finger  this  position  presents  no  advantages  over  the  dorsal ; 
indeed,  it  is  decidedly  inferior,  seeing  that  the  inner  organs  have  gravi- 
tated away  from  the  outer.  For  the  same  reason  the  bimanual  cannot  be 
performed  satisfactorily  in  this  position,  aside  from  the  awkwardness  of 
the  attempt.  The  external  genitals  may,  of  course,  be  inspected  nearly  as 
well  as  in  the  dorsal  position,  the  integrity  of  the  perineum  be  tested,  and 
as  for  the  anal  region,  it  may  be  more  closely  examined.  It  is  in  this 
position  that  the  rectum  may  be  everted  by  means  of  a  finger  in  the 
vagina,  and  a  fissure  or  ulcer  readily  brought  to  view.  Frequently, 
by  means  of  one  or  two  fingers,  Douglas's  cul-de-sac  may  be  more 
carefully  explored  than  in  the  dorsal  jjosition,  and  the  nature  of  a 
post-uterine  tumor  better  appreciated.  The  extent,  also,  to  which  pos- 
terior adhesions  limit  the  mobility  of  the  uterus  may  be  more  correctly 
determined,  and  the  backward  displaced  uterus 'more  effectually  elevated 
by  the  finger  in  the  lateral  position.  Barring  these  exceptions,  the  chief 
utility  of  this  position,  as  intended  by  Sims,  its  originator,  is  the 
exposure  of  the  vaginal  vault  by  means  of  the  speculum  he  devised, 
and  which  has  made  much  of  modern  gynecology  a  possibility. 

Specular  Examination  in  the  Lefi-lateixd  Position. — There  is  but  one 
speculum  of  use  in  the  lateral  position,  and  this  is  the  duckbill  or 
Sims's.  The  cylindrical  speculum,  the  various  bivalves  and  multi- 
valves,  may,  of  course,  be  inserted  into  the  vagina,  but  the  disad- 
vantages are  the  same  as,  and  the  advantages  no  greater  than,  have 
already  been  noted  under  the  dorsal  j)osition.  What  we  need  in  the 
lateral  position  is  a  perineal  retractor  and  an  instrument  for  dejiressing 
the  anterior  vaginal  wall.  These  purposes  Sims's  duckbill  speculum 
and  his  depressor  subserve  perfectly. 

The  chief  bar  to  the  general  use  of  the  unmodified  duckbill  is 
the  fact  that  an  assistant  to  hold  it  is  practically  a  necessity  when  it 
is  desired  to  introduce  instruments  into,  or  to  make  applications  to, 
the  uterine  cavity.     It   is   possible   to    perform    these    manipulations 


I'llYSlCAL   SfGNS. 


311 


alone,  cxccptioiiallv,  if  llif  (xaiiiiniiiu-tal)!"'  Iiavc  tln'  lateral  iiieliiia- 
tion,  the  uterus  l)e  in  fair  pusitiuii,  and  the  vaginal  walls  not  markedly 
relaxed  ;  for  under  sueh  favorable  eireumstanees  the  anterior  va;,nnal 
wall  will  <;ravitale   upward,  the  de|)iv»or   may  he  dis|)ensed  with,  and 


I-'k;.  120. 


b'lo.  121. 


<^ 


Sims's  Depressor. 

the  examiner's  rio-lit  hand  is  thus  left  free  to 
manii)ulate  as  he  ))leases.  As  a  rule,  however, 
if  the  examiner  l)e  alone,  hoth  his  hands  arc 
occupied,  the  one  with  the  si)eculum  and  the 
other  with  the  dej)ressor,  .so  that  he  can  ac- 
complish nothing  beyond  getting  a  view  of 
the  cervix.  And  therefore  it  is  that  Sim.s's 
original  instrument  has  been  .so  variously 
modified,  nsually  in  order  to  make  it  .self- 
retaining.  AVheu  we  consider  how  indispen- 
sable Sims's  .speculum  is  for  both  diagnostic 
and  therapeutic  purposes,  and  therefore  how 
essential  it  is  that  the  general  practitioner,  the 
exigencies  of  whose  practice  do  not  reqnire  the  constant  attendance  of  a 
nurse,  shonld  be  able  to  scientifically  nse  this  instrument  when  using  it 

Fig.  122. 


Sims's  Speculum. 


Hunter-Erich  Speculum. 


at  all,  we  are  not  slow  to  accord  a  word  of  praise  to  each  gentleman 
who  has  aimed  at  modification,  even  though  of  all  the  various  forms 
there  is  scarcely  one  which  is  not  open  to  objection,  largely  on  the  score 


312 


G  YNECOLO GICAL  DIA  GNOSIS. 


of  complexity.  Without  any  desire  to  be  invidious  I  shall  refer  here 
to  only  two  modified  Sims's  which  may  be  used  to  advantage  without 
the  assistance  of  a  nurse.  The  one  is  Hunter's  modified  Erich,  with 
which,  although  I  am  not  personally  familiar,  I  am  assured  by  many 
gentlemen  any  desired  manipulation  is  possible.  It  is  in  appearance 
rather  complicated,  but  after  a  certain  amount  of  practice  much  time  is 
not  required  for  adjustment.  It  is  not  possible  to  give  a  clear  descrip- 
tion of  this  instrument  in  words,  and  I  content  myself  with  figuring  it. 
Another  modified  form  of  Sims's  speculum,  which  from  extensive  per- 
sonal experience  I  can  recommend,  is  that  devised  by  Thomas,  essen- 
tially modified  by  M.  D.  Mann,  and  recently  altered  in  certain 
respects  by  myself.  The  original  instrument  had  a  sacral-piece 
attached  to  it,  and  was  more  complicated  than  the  later  models. 
Mann  dispensed  with  this  piece,  and  at  the  same  time  had  the  blade 
and  depressor  lengthened  and  broadened.  The  instrument  then  con- 
sisted of  a  Sims's  blade  with  attached  depressor,  this  latter  so  articu- 
lated to  the  blade  as  not  to  interfere  in  any  way  laith  the  field  of  vision 
nor  with  instrumental  manipulation,  and — a  most  important  point — so 
as  not  to  distend  in  the  least  the  ostium  vagince.     Further,  a  hook  (Fig. 


Fig.  1 23. 


1.  Mann's  Speculum. 


2.  Tenaculum  for  Mann's  Speculum. 


123,  A)  was  placed  on  the  depressor-shaft  to  which  the  tenaculum,  used 
to  draw  down  or  steady  the  uterus,  might  be  attached.  This  instrument 
is  shorn  of  the  objections  common  to  other  modified  Sims's.  I  have 
recently  had  the  instrument  altered  by  adapting  the  depressor  to  the 
lower  surface  of  the  blade,  fitting  a  flange,  to  hold  up  the  superior 
buttock,  to  the  upper  surface  of  the  blade,  and  by  shortening  the 
depressor  bar.  This  instrument  may  be  held  by  the  left  hand,  or 
else,  when  the  depressor  handle  has  been  screwed  down  and  the  handle 


I'll  y SIC M,  srnxs. 


.'ii;i 


of  the  instrumont  removed,  we  lia\c  d  .svY/'-rr/r/////?}// speciiliim,  nnd  hoth 
liauds  are  free.  1  liave  tested  this  iiisti'iimeMt  iiiitldidly,  and  am  aide 
with  it  to  pcilonii,  in  Sinis's  position,  unassisted,  any  inanij)uhition 
(applications  to  endometrium,  <  iircttinji',  ete.)  proper  to  olliee  practiee. 

()ther  I'orms  of  s|)eeula  devise<l  as  seli-i'etaininji,-  are  those  of  Kminet 
and  (if  StudK'v  and  Darrow.  These  are,  however,  eom|)lieate(l,  and  are 
a|)t  til  alarm  the  patient  \)v  the  time  and  manipuhitiou  necessary  fur 
tlu'ir  adjustment.  I  helieve  that  either  through  the  IIunter-Ericli  or 
throuiili  Mann's  speculum,  or  its  modification,  the  general  })ractitioner 
^\■ill  he  ahle,  without  an  assistant,  to  make  a  correct  diagnosis  and  aj)j)ly 
the  re([uisite  treatment ;  and  that  there  is,  therefore,  no  longer  any  excuse 
tor  the  halfway  measures  commonly,  particularly  in  Europe,  resorted  to 
through  the  cylindrical  or  nudtivalve  instruments. 

Introdiidion  of  Sim.s's  SpcvK/itin. — This  instrument  may  be  intro- 
dueed  either  along  the  index  finger  of  the  right  hand  as  a  guide,  or 


Fio.  124. 


Munde's  Flange  Speculum. 

else  independently  of  a  guiding  finger.  I  much  prefer  the  latter  meth- 
od, mainly  because  thereby  soiling  of  the  finger  is  avoided.  The 
speculum  is  readily  inserted  as  follows:  The  examiner,  sitting  on  a 
stool  or  chair  a  little  to  the  left  of  his  patient,  separates  the  labia  with 
the  thiiml)  and  index  of  the  left  hand,  and,  holding  the  speculum,  pre- 
viously lubricated,  between  the  fingers  of  his  right  hand,  inserts  the 
point  of  the  blade  into  the  vulvar  cleft  and  pu.shes  the  blade  along  the 
])osterior  vaginal  wall.  If  care  be  taken  to  keep  the  blade  ])ointing 
backward  toward  the  coccyx,  it  \vill  necessarily  seek  the  posterior  cul- 
de-sac  and  lie  behind  the  cervix.  The  speculum  is  now  to  be  trans- 
ferred to  the  left  hand  and  the  perineum  retracted  with  an  upward 
inclination.  The  right  hand.  In-  means  of  the  depressor,  pushes  down 
the  anterior  vaginal  wall,  tlie  cervix  ordinarily  comes  into  view,  and 
the  speculum  is  handed  to  the  nurse,  if  one  be  present,  who  holds  it  in 


314  GYNECOLOGICAL  DIAGNOSIS. 

position  with  her  right  hand,  whilst  her  left  j)nlls  up  the  superior  but- 
tock. This  last  stej?  is  rendered  unnecessary  if  the  speculum  have 
adaj)ted  to  it  the  flange  devised  by  Munde  for  keeping  the  right  but- 
tock out  of  the  field  of  vision — a  modification  which  will  be  found  par- 
ticularly of  use  when  the  nurse  is  desired  to  hold  some  other  instru- 
ment for  the  examiner,  and  can  do  so  in  her  left  hand.  Exceptionally, 
in  pluriparse  with  loose  and  flabby  vaginal  walls,  or  when  from  ante- 
rior displacement  or  distortion  of  the  uterus  the  cervix  lies  far  back  in 
Douglas's  cul-de-sac,  it  is  impossible  to  obtain  a  satisfactory  view  of 
this  organ  without  resorting  to  a  further  instrument,  the  tenaculum. 

Fig.  125. 


Emmet's  Tenaculum. 

By  hooking  this  into  the  anterior  lip  of  the  cervix  and  making  gentle 
traction  the  cervix  may  be  brought  into  view.     The  traction  must  be 

Fig. 126. 


Sims's  Tenaculum. 


gentle,  especially  if,  as  a  result  of  our  bimanual  examination,  we  have 
obtained  evidence  of,  or  have  reason  to  suspect,  recent  or  chronic  cellu- 
litis or  pelvic  peritonitis. 

The  speculum  in  position,  we  are  now  able  to  note  the  appearances 
of  the  cervix. 

The  Appearances  of  the  Cervix  through  Sims^s  Speculum. — The  chief 
cervical  appearances  to  be  noted  are  the  color,  shape,  condition  of  the 
external  os,  and  the  discharge  issuing  from  it.  The  color  of  the  cervix 
varies  from  light-pink,  the  normal,  to  blue  or  violet,  a  sign  of  conges- 
tion and  suggestive  of  pregnancy,  subinvolution,  ovaritis,  mechanical 
interference  with  the  pelvic  circulatory  system.  The  shape,  unaffected 
by  disease,  may  be  roundish,  conical,  or  flattened.  The  site  of  the 
external  os,  in  the  centre  or  to  one  side,  its  size,  pinhole  (a  frequent 
explanation  of  sterility),  patent  to  the  finger  (suggestive  of  recent  mis- 
carriage, disease  of  the  endometrium  or  endocervix),  fissured  or  lace- 
rated (evidence  of  childbearing),  are  further  j^oints  to  be  noted.  The 
distinction  between  an  erosion,  ulceration,  and  laceration  may  now  be 
readily  made  without  the  source  of  error  referred  to  under  the  subject 
of  multivalve  specula.  The  eroded,  everted  mucous  membrane  of  a 
lacerated  cervix  may  be  rolled  in  by  tenacula,  and  the  superficial 
denudation  of  epithelium  accompanying  a  catarrhal  erosion  is  clearly, 


I'llYsiCAL   SIONS.  315 

at  ;i  <il:iii('(',  tlillrrt'iil  IVoiii  (lie  cxcaxatinii  the  rcsnlt  oC  ulceration.  TIm- 
color  and  the  natiircol"  tlic  discliarui'  issuing-  I'roiii  tlic  external  os  jiivc 
us  an  inklinL!;  of  the  ])i-ol»al)I<'  main  source,  jxtints  already  referred  to 
under  tlie  head  ol"  tlic  diiiital  examination.  The  reaction  of  thi.s  di.s- 
eharu'i'  niav  he  tested,  and  if  acid  will  oiler  a  valid  explanation  ol"  the 
eausi"  of  sterility. 

Introduction  of  the  Probe. — Where,  owing  to  narrow  external  os  or 
cervical  canal,  or  to  sharj)  flexion,  it  was  found  inipossihie  to  pass  the 
sound  in  the  dorsal  pi>sition,  the  prohe — a  miniature  flexible  soun<l — 
mav  now  l)e  used.  It  goes  without  saying  that  previous  to  tiie  attempt 
to  pass  this  in.-trunient  the  position  of  the  uterus  has,  where  possible, 

Fig.  127. 


Emmet's  Flexible  Probe. 

been  a.scertained  binianually,  and  that  the  absence  of  the  contraindi- 
eating  factors  already  referred  to  has  been  determined.  The  probe  is 
to  be  bent  according  to  the  direction  it  will  probably  have  to  take  in 
order  to  reach  the  fundus,  and  the  depth  of  the  canal  may  be  measured 
and  its  sensitiveness  ascertained,  even  as  noted  when  speaking  of  the 
sound. 

It  is  not  in  place  to  describe  here  the  further  nses  of  Sims's  position 
and  speculum,  such  as  for  the  efficient  tamponade  of  the  vagina  and  the 
making  of  applications  to  the  uterine  cavity.  The  value  of  this  posi- 
tion and  speculum  for  the  use  of  special  instrumental  diagnostic  means 
will  be  noted  farther  on. 

The  Genu-Pectoral  Position. — For  purposes  of  diagnosis  this 
position  is  of  little  value ;  and  fortunately  so,  because  it  is  a  difficult 
position  for  the  patient  to  retain  for  any  length  of  time,  and  one  par- 
ticularly oifensive  to  her  modesty.  Its  chief  uses,  and  \qv\  important 
ones,  are  for  the  thorough  tamponade  of  the  vaginal  vault,  and  for  the 
reposition  of  a  dis])laeed  uterus  M'hich  defies  our  efforts  in  tlie  left- 
lateral  position.  To  assume  it,  the  patient  kneels  at  the  e<lge  of  tlie 
table  and  leans  forward,  so  that  her  chest-wall,  not  her  eli)ows,  shall 
rest  on  the  mattress.  Obviously,  gravity  may  now  act  to  the  greatest 
possible  advantage,  so  that,  when  on  lifting  the  perineum  with  Sims's 
speculum  the  vagina  is  opened  and  the  pneumatic  pressure  of  the  air 
is  superadded,  the  pelvic  organs,  unless  jxithological  alterations  inter- 
fere, sink  upward  and  dowuAvard  beyond  the  efficient  reach  of  the 
examining  finger.     It  is  in  this  position  that  the  length  of  th(^  infra- 


316  GYNECOLOGICAL  DL4.GN0SIS. 

vaginal  portion  of  the  cervix  may  be  accurately  determined ;  but  with 
this  exception  and  the  therapeutic  measures  noted  above,  the  genu- 
j)ectoral  position  fulfils  no  purpose  which  the  left-lateral  may  not  to 
better  advantage. 

The  Erect  Position. — Examination  in  this  position  is  attained  by 
the  patient,  with  legs  separated,  standing  in  front  of  the  examiner, 
whilst  he  rests  on  one  knee  or  sits,  and,  introducing  the  hand  under 
the  clothing,  carries  the  index  finger  along  the  perineum  into  the 
vagina.  For  diagnosis  this  position  is  rarely  available,  for  under  us- 
ual conditions  the  uterus  lies  more  horizontally,  and  the  cervix,  hence, 
is  far  back  out  of  easy  reach  of  the  finger.  In  this  position,  however, 
we  may  determine  the  elFect  of  intra-abdominal  pressure  on  the  pelvic 
organs,  and  detect  downward  sagging  of  the  uterus  which  was  not 
appreciable  in  the  dorsal  position,  thereby  finding  an  explanation 
for  backache  or  bearing-down  sensations  otherwise  of  obscure  origin. 

Special  Instrumental  or  Exploratory  Means  op  Diagnosis. 

Having  now  considered  the  general  and  routine  measures  of  use  in 
the  diagnosis  of  disease  of  the  female  generative  organs,  I  proceed  to  a 
description  of  those  special  means,  recourse  to  any  one  of  which  may  be 
necessary  in  order  to  complete  our  diagnosis.  I  shall  consider  these 
measures  under  the  following  subdivisions  : 

A.  Instrumental  examination  of  the  urethra,  bladder,  and  rectum ; 

B.  Dilatation  of  the  cervix  for  diagnostic  purposes ; 

C.  Curetting  of  the  cervix  and  uterus  for  diagnosis ; 

D.  Artificial  prolajDse  of  the  uterus  for  diagnosis  ; 

E.  Aspiration  through  the  vagina  or  abdomen  for  diagnosis. 

A.  Instrumental  Examination  of  the  Urethra,  Bladder, 
AND  Rectum. — The  instruments  at  our  disposal  for  examination  of 
the  urethra  and  bladder  are  few  in  number,  and,  owing  to  the  limited 
expansibility  of  the  meatus  and  urethra,  the  ocular  evidence  of  disease 
obtainable  is  at  best  unsatisfactory.  The  use  of  the  finger  for  purposes 
of  exploration  I  must  consider  unjustifiable  unless  there  is  strong  pros- 
pect of  sufficiently  relieving  our  patient  to  atone  for  the  not  impossible 
laceration.  Ordinarily,  by  means  of  the  sound — the  uterine  will  gen- 
erally suffice — we  may  detect  the  same  pathological  conditions  as  the 
finger  could,  and  yet  we  thereby  subject  our  patient  to  no  risk  of  injury. . 
In  addition  to  the  sound,  the  speculum  and  the  endoscope  are  the  instru- 
ments available  for  diagnosis,  and  they  are  best  introduced  with  the 
patient  in  the  dorsal  position.  The  sound  wall  determine  the  sensitive- 
ness of  the  urethra  and  bladder,  the  smoothness  or  roughness  of  the 
mucous  membrane,  the  presence  of  stone  or  of  large  foreign  growths. 
Sensitiveness,   varying   in   degree,  will    suggest   caruncles,  fissure,  or 


SPECIAL  LWSTJtUMJ.xr.ii.  .1/ /•;. I .v.v  or  j)i.\(;.\()sis. 


in 


cystitis.  lv\;iiiiiii;itioii  ol"  the  iii-iiic  will  (litliTciitiatc  tlic  lattci-,  and 
recourso  t<>  iiis|)('cti(»ii,  the  rnnncr.  The  iirctliral  s|m(iiIiiiii  is  coii- 
stnictctl  citlici-  nl"  <;lass,  liihiilar  in  lltnii,  or  of"  metal,  uilii  divcrtrciit 
hraiiclics.  Tliroiijili  siicli  sju'ciila  tin-  cdloi-  and  iiitc^irity  of  the  iirctliral 
mucous  uiembrane  may  he  noted,  earuneles  (leteete< I,  au<l,  except ionalK, 
a  fissure  at  the  vesical  neck.  Refleeted  li^ht  will  jrreatly  assist  in  such 
an  examination.  In  the  ahsence  of  a  speciilnm  the  oidinarv  (lressin<;- 
forccps  or  a  steel-hranched  uterine  dilatoi-  will  allow  us  t(j  in.«-pect 
tlie  urethral  mucous  mcmi)i"ane.  As  typical  of  the  endoscope,  I 
instance  that  of  l>r.  Skene  of  Brooklyn,  althoujih,  excej)t  in  his 
hands,  it  has   not  l)cc(»iiic  widely  us(m1.      It  consists  of  two  jx^rtions — a 

Fi(i.  128. 


Skene's  Endoscope. 

glass  tube  and  a  blackened  secti(jn  of  a  cylinder  containing  a  mirror 
placed  at  an  acute  angle  at  its  distal  extremity.  The  glass  tube  fits 
into  the  cylindrical  section  ;  the  mirror,  attached  to  a  handle,  lies  in 
the  glass  tube  ;  and  ^vhen  the  cylinder  has  been  introduced  into  the 
urethra  light  reflected  from  a  head-mirror  upon  the  mirror  in  the  tube 
illuminates  the  urethral  mucous  membrane,  and  the  trained  eye  may 
detect  alterations  within  the  urethra.  Beyond  this,  whether  speculum 
or  endoscope  ])e  used,  inspection  extends  to  an  unsatisfactory  degree, 
owing  to  the  difficulty  of  illuminating  the  cavity  of  an  organ  the  walls 
of  Avhich  constantly  tend  to  ai)i>roximatc  except  when  dist(>nde(l  by 
fluid  or  disease.  Fortunately,  diseased  conditions  of  the  bladder  may 
ordinarily  be  diagnosticated  by  means  of  the  sound  and  associated 
■examination  of  the  urine,  and  therefore,  from  a  diagnostic  standpoint, 
it  rarely  becomes  necessary  to  resort  to  either  the  speculum  or  the  endo- 
scope. It  is  in  place  here  to  refer  to  the  possibility  of  sounding  the 
ureters,  and  of  occluding  one  or  the  other  by  the  finger,  in  order  to 
detect  disease  of  the  urinary  tract  above  the  l)ladder,  and  limited  pos- 
sibly to  one  ureter  or  kidney.  Such  mann?uvres  are  yet  in  their  infiincy, 
and,  whatever  the  possibilities  for  the  future,  up  to  the  present  have 
yielded  no  results  of  a  practical  nature. 


318 


GYNECOLOGICAL  DIAGNOSIS. 


I  will  simply  refer  here  to  a  surgical  method  of  diagnosis  which  has. 
yielded  excellent  results  in  the  hands  of  the  originator,  Dr.  Emmet, 
and  which  is  possibly  destined  to  take  the  lead  of  all  other  methods  of 
diao-nosticatino;  disease  of  the  bladder  and  its  neck.  This  method  con- 
sists  in  buttonholing  the  urethra,  and  the  procedure  will  be  described 
in  connection  with  the  special  diseases  of  the  urinary  tract. 

The  necessity  of  careful  rectal  exploration,  in  every  case  where  the 
symptoms  are  otherwise  unsatisfactorily  explained,  has  already  been 
insisted  upon.  Specular  examination  of  the  rectum  as  a  routine  meas- 
ure is  not  necessary,  but  it  should  never  be  neglected  in  any  case  where 
there  exists  a  suspicion  of  disease  of  the  upper  rectum.  This  examina- 
tion is  painful,  ordinarily  requires  previous  distension  of  the  sphincter; 
and  it  is  necessary,  therefore,  to  resort  to  anaesthesia.  The  advisability 
of  a  thorough  cleansing  of  the  lower  bowel  by  purgative  or  enema, 
before  resorting  to  rectal  examination,  is  sufficiently  apparent.  The 
general  indications  for  a  specular  rectal  examination  are  complaint  of 
pain  before,  during,  or  after  defecation  and  the  presence  of  blood,  pus, 
or  membrane  in  the  dejections,  provided  the  signs  find  no  explanation 
in  the  digital  eversion  of  the  rectal  mucous  membrane  alreadv  referred 
to,  and  in  the  absence  of  such  an  obvious,  although  not  always  suf- 
ficient, cause  as  hemorrhoids.  The  specula  of  utility  are  either  tubular 
or  valvular.  For  general  purposes  the  blade  of  a  small  Sims's  will 
suffice  for  diagnosis,  although  a  much  more  convenient  instrument, 
when  the  examiner  is  without  an  assistant,  is  that  devised  by  Kelsey 

of  New  York.    The  special 
^^*^'  advantage  of  this  instru- 

ment is  the  fact  that  a 
large  surface  of  the  rectal 
mucous  membrane  may  be 
inspected  through  it  with- 
out the  anus  being  stretch- 
ed to  any  great  degree. 
Whatever  the  form  of  in- 
strument used,  either  re- 
flected light,  or  that  from 
one  or  another  of  the  port- 
able electric  light  appara- 
tuses recently  devised,  is 
almost  a  necessity  for  exact 
diagnosis.  The  patient 
may  occupy  either  the  dorsal  or  the  left-lateral  position,  although  a  better 
view  may  be  obtained  from  the  latter.  The  points  to  be  noted  through 
the  speculum,  some  of  which  must  escape  the  examining  finger  alone, 
are — the  color  and  integrity  of  the  rectal  mucous  membrane,  erosion,, 


Kelsey's  Rectal  Speculum. 


SPECIAL   rNSTBUMhWTAL   .1/ /■;.  1  .V.V   OF  DIAt.WOSlS.  :',]'.} 

ulccriitiiin   ami    lissurc,  |i()l\|)i,  carciiKniia,  ami    li>liil<ni.-   ()|>ciiiiiL''s   iVinii 
ischio-i'cclal   nv  pelvic  ahsccsscs. 

y>.  Dll-ATATIOX  .OF  'rilK  ( 'KI;\I.\  Koi;  DiACNosilc  I'llM'oSKS. —  In 
order  lo  e\|>lt>re  the  iiiteridi-  df  the  uterus  with  the  liiiiicr,  the  cervical 
canal  iiui>t  lirsl,  apart  tVoiii  the  puerperal  state,  he  widely  dilated.      To 

Fiti.  i:JO. 


Goodell-EUinLaT's  Dilators. 


accomplish  this  we  have  at  our  disposal  three  classes  of  instruments : 
1,  steel-branched  dilators  and  conical  graduated  steel  or  hard-rubber 
sounds ;  2,  rubber  dilatable  tubes ;  3,  tents. 

The  steel-branched  dilators  are  the  best  agents  for  rajnd  dilatation, 
and  will  rarely  fail  in  accomplishing  their  purpose,  except  where  there 
exists  excessive  rigidity  of  the  cervix  (from  hyperplasia  or  cicatriza- 
tion). As  types  of  these  dilators  I  would  mention  that  of  EUinger 
and  that  of  Palmer.  EUinger's  instrument  is  scarcely  powerful  enough, 
unless  the  cervix  is  readily  dilatable,  and  it  is  also  objectionable  on 
account  of  the  number  of  lodging-])laces  for  dirt  it  offers.  Goodcll  of 
Philadelphia,  however,  speaks  of  it  highly  as  modified  by  himself,  and 
justly  so,  since  his  modification  has  essentially  improved  the  instru- 
ment. He  has  had  it  constructed  of  two  sizes — a  small  with  slender 
blades,  and  a  larger  one  Avith  powerful  blades  which  do  not  feather, 
and  with  a  screw  attachment  to  separate  the  blades.  This  .screw-attach- 
ment is  a  real  advantage,  for  thereby  we  are  enabled  to  dilate  slowly, 
allowing  the  muscular  fibres  of  the  cervix  to  yield  to  the  applied  force. 


320 


GYNECOLOGICAL  DIAGNOSIS. 


instead  of  rupturing  them.  Another  excellent  dilator  is  Palmer's.  It 
also  is  furnished  with  a  screw  attachment,  and  it  will  dilate  to  quite 
one  inch,  sufficient  to  allow  the  average  index  finger  to  pass.  The 
larger  Goodell-Ellin^er  dilates  to  an  outside  width  of  one  and  a  half 
inches. 

The  conical  graduated  sounds  will  accomplish  dilatation  as  effectively 
as  the  steel-branched  dilators,  although  they  take  more  time,  and  their 
use  has  the  decided  disadvantage  of  requiring  counter-pressure  on  the 


Fig.  131. 


Light. 


Heavy 


Palmer's  Dilators. 


fundus  through  the  abdominal  walls  ;  and  in  many  cases  this  manoeuvre 
fails,  for  the  simple  reason  that  the  body  of  the  uterus  is  too  markedly 
displaced  backward  to  be  reached  by  the  external  hand.  However  valu- 
able these  sounds,  therefore,  for  purposes  of  treatment  where  dilatation 
is  desired  for  digital  exploration,  I  can  conceive  them  only  of  use  where, 

Fig.  132. 


Hanks's  Cervical  Dilator. 


through  the  smaller  sizes,  sufficient  preliminary  dilatation  is  requisite  to 
allow  of  the  introduction  of  a  branched  dilator.  These  sounds  have 
been  variously  constructed  and  modified.  The  most  serviceable  prob- 
ably, certainly  as  good  as  any  others,  is  the  set  devised  by  Hanks  of 

New  York. 


SPECIAL  iysTi:rMi:\T.\L  Mi.wys  of  in.iayosis. 


321 


'I1ir  nil.lxi-  iiiIm-,  (.1-  \v:itcr-(lil:it(.r>,  arc  al.-n  rtl'cclivc  <lilatiu^  ajziciitji, 
Imt  thcv  aiv  sittucr  in  action   tliaii  tlic  l»raiicli<Ml  (lilatr.i>,  and  have  tlie 
disailvantauc  common  lo  all  rnbln'r,  of  lVc(incnlly  proving  (Icfcctivf  at 
the  v«TV  time  when   sci-vicc 
IS  r('(|nirc(l.       I  Iksc  instni- 
mcnts   arc    rc|>i-csciito(l    by 
Molcsworlirs  and  Eiiimct's. 

Tents  are  tlie  slowest  of 
all  dilating  agents,  and  for 
|)iirelv  exploratory  pnrposes 
tlicv  will  doubtless,  in  gen- 
oral,  yield  to  the  branehed 
dilators,  except  w  here  there 
is  a  verv  rigid  cervix  to 
be  overcome.  They  p(wse.ss, 
however,  certain  therapeutic 
uses  for  which  they  must 
be  retained.  They  are  con- 
structed either  of  compress- 
e<l  sponge,  of  laminaria,  of 
tnpelo, — these,  at  least,  are 
the  sole  agents  of  value  for 
sufficient  dilatation  to  allow 
of  exploration. 

Sponge  tents  have  long 
been  in  fav<jr  on  account 
of  their  great  and  equable 
expansile  power.  The  great 
objection  to  these  tents  is 
the  fact  that  their  use  is  li- 
able to  be  followed  by  sep- 
sis, notwithstanding  careful 
antisepsis  both  in  prejiara- 
tioii  and  in  introduction.  For  this  reason,  therefore,  they  are  gradu- 
ally being  superseded  by  the  tnpelo  for  exploratory  ]iurposes. 

The  laminaria  has  but  little  dilating  power  comparatively,  and  this 
power  is  lea.st  effectual  at  the  very  p(Mnt  where  dilatation  is  most 
desired — the  internal  os.  This  form  of  tent,  therefore,  may  lie  ruled 
out  as  an  agent  of  value  for  dilatation  to  be  followed  by  digital  ex})l or- 
ation. 

The  tnpelo  (root  of  the  Xyssa  aqnatk-ci)  is  the  agent  j^rrr  exfcUence  in 

tent  form  for  dilating  pnrposes.     Its  expansibility  is  nearly  equal  to 

that  of  the  sponge,  it  dilates  equably  throughout  its  length,  it  does  not 

abrade  the  cervical  tissues  to  the  same  extent  as  the  sponge,  it  is  excep- 

VoL.  I.— 21 


Emmet's  Water-Dilator. 


322 


GYNECOLOGICAL  DIAGNOSIS. 


tional  for  its  proper  use  to  be  followed  by  sepsis.      The  sphere  of  dila- 
tability  of  this  tent  is  well  represented  in  the  accompanying  cut  (Fig. 


Fig.  134. 


Molesworth's  Hydrostatic  Dilator. 

135).  The  tupelo  was  introduced  to  the  notice  of  the  profession  by  Dr. 
Sussdorff  of  ISTew  York  City,  and  may  now  be  obtained  in  varying  sizes 
and  lengths,  although  a  large  one  may  be  readily  whittled  to  the  desired 
size. 

The  indications  in  general,  aside  from  therapeutic  purposes,  for  the 


Fig.  135. 


r'r^ 


Dilatability  of  Tupelo  Tents  (after  Mund^). 


use  of  dilating  agents  are  hemorrhage  from  the  uterus  not  explainable 
by  recourse  to  other  diagnostic  means,  and  the  necessity  of  ascertaining 


SPECIAL   lNSTRUMEi\TAL   .UAVl.V.S'   OF  DIAGNOSIS.  323 

tlic  IdCMtiiHi  and  atlai'liiiiciil  ol"  an  intra-iitci-iiic  u'i''»\vtli.  I  )ilatati<tii 
siiMicicnl  tor  i-xploratory  [nuposcs  should  ever  he  considered  a  minor 
()j)eration,  i'e((uii'ini:-  anu'stliesia,  and  is  to  he  perl'ornied  at  the  patient's 
house;  and  altei-  the  use  of  any  (hlatini;-  a^cnt  the  patient  .-hould 
remain  in  hed  Irom  twenty-lour  to  thii'ty-six  hours,  and,  as  a  prophy-j 
laetie  measure,  opium  shouM  he  achninistered  and  heat  applieil  to  tlie 
al)domen.  In  ea.-e  the  s|)onii'e  tent  is  useil,  it  is  a  eai-(linal  ride  not  to 
follow  the  lirst  tent  immediately  hy  another,  and  disregard  of  this  rido 
is  respousihie  foi-  many  a  ease  of  fatal  septietemia.  'J'he  .same  eiiiiti(Mi 
is   not   applieahle   to   the  tujH'lo  tent. 

Ordinarily,  where  dilatation  is  desired  for  diaj!;n()stie  pnr|)oses,  the; 
cervical  canal  will  he  sullieiently  patulous  to  allow  of  the  intrcxiuction 
of  the  dilatino-  a>i-eut  without  previous  incision  (»f  the  external  os. 
Should  this  he  necessary,  however,  there  is  little  added  risk,  except 
where  a  sponoe  tent  is  the  dilating-  agent,  provided  due  antise^jtic 
precautions  are  taken  before  and  after  the  operation. 

From  what  precedes,  it  is  apparent  that  I  favor  as  dilating  agents, 
for  purposes  of  exploration,  the  steel-branched  dilators  where  rapid 
dilatation  is  desired,  and  the  tupelo  tent  in  case  of  excessive  cer\'ical 
rigidity  and  where  the  slower  action  of  the  tent  may  be  awaited.  Both 
the  dilator  and  the  tent  are  best  introduced  through  Sims's  specnlum, 
the  position  of  the  uterus  having  been  first  determined  bimanually. 
The  vtigiua  should  always  first  be  irrigated  with  clean  boiled  Avater,  to 
which  carbolic  acid  or  corrosive  snblimate  may  be  added.  The  size  of 
tent  snitable  to  the  case  is  readily  introduced  by  grasping  it  bv  an  ordi- 
nary dressing- forceps,  the  cervix  being  steadied  by  a  tenaculum  fixed 
in  its  anterior  lip.  In  case  the  Goodell-Ellinger  dilator  be  used,  the 
smaller  size  may  be  passed  first,  and  dilatation  by  it  will  pave  the 
way  for  the  introduction  of  the  larger  size.  Occasionally,  independ- 
ently of  the  puerperal  state,  the  cervical  canal  may  be  dilated  by  means 
of  the  finger,  and  wherever  possible  the  finger  of  course  ranks  above 
all  other  agents. 

Whatever  the  means  employed,  dilatation  once  accomplished,  the 
patient  should  lie  in  the  dorsal  position  and  the  index  finger,  pre- 
viously disinfected  with  care,  is  to  be  jiassed  to  the  fundus,  this  in  turn 
being  depressed  through  the  abdominal  walls.  We  are  now  in  a  posi- 
tion to  examine  carefully  the  entire  endometrium.  Thus  the  finger 
notes  the  smoothness  or  roughness  of  the  mucous  membrane,  and  is 
able  to  detect  the  presence  of  any  foreign  body,  such  as  a  tumor  and 
its  attachment  or  a  remnant  of  secundine  or  placenta,  and  we  may 
resort  at  once  to  the  necessary  treatment.  Our  exploration  ended,  if 
no  surgical  procedure  or  ajiplication  be  resorted  to,  the  uterine  cavity 
should  be  thoroughly  douched  with  hot  water,  plain  or  with  the  addi- 
tion of  some  antiseptic,  and  in  case  of  hemorrhage  it  may  be  swabbed 


324  GYNECOLOGICAL  DIAGNOSIS. 

with  tincture  of  iodine,  and  both  the  cervical  cavity  and  the  vao-ina 
tamponed. 

C.  The  Curette  as  a  Diagnostic  Agent. — In  this  instrument 
we  possess  a  very  vahiable  means  of  acquiring  information  in  reo-ard 
to  the  contents  of  the  uterine  cavity  and  the  condition  of  its  lining 
membrane.  There  are  two  varieties,  the  sharp  and  the  dull.  For 
diagnostic  purposes  the  latter  alone  is  of  use.  The  former  has  thera- 
peutic uses  which  the  latter  can,  at  times,  only  partially  fulfil.  Eeca- 
mier,  the  inventor  of  the  curette,  had  it  constructed  Avith  cutting  edge, 
and  therein  he  was  imitated  by  Sims  in  his  instrument.  It  was 
reserved  for  Thomas  to  devise  the  dull  instrument  and  to  point  out 
the  information  to  be  derived  from  its  use.  The  dull  curette  is  made 
in  three  sizes,  has  a  flexible  shaft  alloAving  of  bending  to  any  desired 
curve,  and  the  scraping  edge  is  smoothly  flattened  so  as  to  prevent  its 
injuring  the  endometrium. 

Fig.  136. 
Thomas's  Dull  Curette. 

The  indication,  in  general,  for  the  dull  curette  may  be  said  to  be 
uterine  hemorrhage  or  profuse  leucorrhoea  which  yields  neither  to  gen- 
eral nor  to  local  measm^es,  and  suggests,  therefore,  the  j)resence  of  an 
intra-uterine  gro"\vth  or  degeneration  of  the  endometrium  requiring 
recourse  to  active  therapeutic  measures.  This  instrument  may  be  used 
with  safety  in  office  practice,  provided  the  object  be  diagnosis.  Where, 
as  the  result  of  its  diagnostic  use,  disease  is  revealed  requiring  resort  to 
the  more  active  use  of  the  dull  or  to  the  sharp  curette,  then  it  is  advis- 
able to  defer  further  manipulation  till  the  patient  can  be  seen  at  her 
house.  The  contraindications  to  the  use  of  this  instrument  are  exactly 
the  same  as  those  which  apply  to  any  instrumental  interference  with  the 
uterine  cavity — suspicion  of  jDregnancy  and  evidence  of  recent  exudation 
around  the  uterus.  No  anaesthetic  is  required,  since  the  use  of  the  curette 
for  diagnosis  is  practically  painless.  Preliminary  dilatation  of  the  cervix 
is  rarely  requisite,  because  in  the  very  cases  where  the  curette  is  indicated 
for  diagnosis  the  hemorrhage  or  leucorrhoea  has  softened  the  cervical  tis- 
sues and  accomplished  dilatation  to  a  sufficient  degree.  Where  this  is 
insufficient,  however,  gentle  dilatation  with  a  steel-branched  dilator  will 
allow  of  the  passage  of  the  smallest  sized  curette,  which  practically  suf- 
fices for  diagnosis  alone. 

The  curette  can  only  effectually  be  introduced  through  Sims's  specu- 
lum, and  it  goes  without  saying  that  the  position  of  the  uterus  should 
first  have  been  determined  bimanually,  and  the  direction  of  its  canal 


Sl'KClAL    L\STnrMi:.\TAL    Mh'.WS   OF  lH.idXOSfS.  .TJ') 

l>V    IllCMIIS    of   tlic    M)llinl    u|-    |>I<i1m'.        Tllc   illt  Indllctinii   of   tlic    clirctt*'    is 

tiicilitatcd  l»N'  liookiii;^'  ;i  (cnMculiini  in  tlh-  nntcrior  li|i  «tt'  tlif  cervix, 
\vlu'rt'l)v  tin-  iitcnis  is  stciidicd,  mikI  l)y  iiiiikiiij;-  ;^ciiti('  down  ward  trac- 
tiiiM  the  axis,  in  case  ol"  lliximi,  is  in  a  iiKa.-nrc  >trai;:litcn('d  ont.  TIm- 
instrument  is  to  l)e  ;x'ven  the  curve  wliieli  the  |>revi<ius  intr(tdueli<>ii  ot' 
the  sound  or  j)rol)e  has  proved  necessary,  and  passed  to  the  I'undns.  It 
i-;  held  liiihtlN'  hetween  the  thiiinl>  and  inch'X.  and  the  entire  endo- 
nu'triuni  is  earetullv  l)ut  <i<'ntly  scra|ied.  The  sensation  coninnnii- 
eatetl  to  the  tiuLl'ers  of  rousxhness  or  smoothness  of  the  eiid(tnietrinm, 
ot"  ine(|ualities  in  its  surlaee,  and  the  g;ratin«;'  sound  often  andihle  as 
tlie  iustnnnent  passes,  in  particuhir,  over  tlie  cervical  mucous  mem- 
hrane,  suti;t;est  in  turn  ])ossil)ilities  even  before  the  dehris  from  the 
curetting  is  examined.  The  uross  appearance  of  the  deljris,  if  any, 
will  frequently  make  our  diaj>nosis  ;  its,  for  instance,  where  munerous 
^granulations  or  vei>,etations  are  removed,  or  where,  not  uncommonly,  a 
portion  of  the  sei'undines  from  a  neglected  or  not  suspected  miscarriage 
is  hrouo-ht  to  light.  AVhere  there  is  any  doubt,  however,  resort  to  the 
mii-roscope  may  reveal  the  structure  typical  of  malignant  disease.  In 
case  of  polypus,  also,  the  curette,  presenting  a  broader  surface  than  the 
sound,  will  give  us  more  definite  information  in  regard  to  its  attach- 
ment. The  aj)[)lication  of  the  curette  with  care  Avill  rarely  be  followed 
by  much  hemorrhage;  still,  the  better  practice  is  to  make  an  afler- 
ap[)lieation  of  iodine  to  the  endometrium,  and  in  cases  where  the 
uterus  is  enlarged  and  heavy  to  tampon  both  the  cervix  and  the 
vagina.     Prophylaxis  can  never  harm,  and  may  do  good. 

D.  AiiTTFirTAL  Prolapse  of  the  Uterus  for  Diagnosis. — This 
diaijrnostic  means  need  rarelv  be  resorted  to.  The  manoeuvre  is  oidv  in- 
dicatetl  where  the  bimanual  examination  fails  to  give  us  exact  informa- 
tion in  regard  to  the  nature  or  insertion  of  a  tumor  closely  related  to 
the  uterus,  and  also  where,  owing  to  great  adipose  development  in  the 
abdominal  walls,  the  external  hand  cannot  depress  the  body  of  the 
uterus  sufficiently  to  enable  the  finger,  exploring  its  cavity,  to  reach 
the  fundus.  I  question  if  it  be  not  wiser  to  attempt  to  finish  our 
exploration  under  anse-sthesia,  for  it  strikes  one  as  crude  to  thoroughly 
dislocate  any  organ  of  the  body  from  out  of  its  natural  })osition.  The 
method  is  rather  more  in  favor  in  Europe  than  with  us,  and  appar- 
ently only  exceptionally  is  damage  inflicted.  The  contraindication  to 
artifieitd  prolapse  is  the  presence  of  exudation,  recent  or  chronic,  around 
the  uterus — a  factor  which  of  itself  would  prevent  the  success  of  the 
manoeuvre,  even  if  the  attempt,  under  the  circumstances,  were  not  to 
be  condemned  on  account  of  the  likelihood  of  relighting  the  inflam- 
matoiy  process. 

Artificial  prolapse  is  accomplished  in-  hooking  a  strong  double 
tenaculum  or  vulsellum  into  the  cervix,  and  slowly  making  traction 


326 


GYNECOLOGICAL  DIAGNOSIS. 


until  the  cervix  appears  at  the  ostium  vaginae.  This  accomplished, 
the  finger  in  the  rectum,  or,  exceptionally,  in  the  bladder,  may  to 
better  advantage  j)alpate  the  posterior  and  anterior  walls  of  the  uterus, 
or  the  finger  within  the  uterine  cavity  may  more  readily  explore  the 
fundus  of  the  uterus.  On  releasing  our  hold  on  the  cervix  the  uterus 
will  return  to  its  position. 

E.  Aspiration  through  the  Yagina  or  Abdomen  for  Diag- 
nosis.— We  possess  herein  a  very  valuable  means  of  obtaining  informa- 
tion in  regard  to  the  contents,  and,  in  a  measure,  in  regard  to  the  nature, 
of  abdominal  and  pelvic  tmuors.  Aspiration  for  diagnosis,  when  care- 
fully performed,  may  be  said  to  be  practically  free  from  danger,  although 
in  general  it  is  wiser  to  explore  at  the  patient's  house.  It  is  necessary 
to  remove  only  a  small  amount  of  fluid ;  such,  for  instance,  as  may  be 
drawn  into  the  ordinary  hypodermic  syringe.     The  large  Dieulafoy 

aspirator  is  therefore,  for 
diagnostic  purposes,  not 
requisite.  A  long  needle, 
attached  to  the  pocket  hypo- 
dermic syringe,  will  reach 
deep-seated  tumors,  whilst, 
of  course,  the  usual  needle 
will  suffice  to  explore  super- 
ficial tumors.  A  very  con- 
venient portable  aspirator 
is  shown  in  the  annexed  cut. 
Dieuiafoy's  Aspirator.  Whatever  the  locality  to 

be  aspirated,  careful  preliminary  disinfection  should  be  the  rule.  In 
aspirating  through  the  vaginal  vault  the  needle  may  be  passed  along 

Fig.  138. 


Emmet's  Aspirator  Syringe. 

the  finger  and  thrust  into  that  portion  of  the  tumor  where  fluctuation 
is  most  distinct,  avoiding,  of  course,  a  part  where  pulsation  marks  the 


sriX'iAL  L\sTnrMi:.\TAL  mi:a.\s  or  dtacxosis.       ?>21 

prcsriice  ol'  an  artcrv  ;  or  else  tlic  va<iinal  vault  may  he  lir.-t  cxijoscd 
tlirou^li  Siins's  spcciiliiin.  The  ^rfoss  apiH'arance  ol'  tlic  fluid  with- 
drawn will  l"i((|iitiiily  iiiaUf  mir  diai^iiosis ;  as,  for  iii!staii<-t',  where 
blood  is  ohtaiiied  from  a  |)ost-iiteriiie  tiiiiioi-(h!i'mato('ele)  or  j)ii.s  (pelvic 
ahscoss).  The  diU'erontial  dia^iutsis  of  al)(lominal  tuiiiors,  hy  exainina- 
tioii  of  the  fluid  removed,  will  usually  recjuire  resort  to  the  mieroseo|)e, 
and  even  then  it  is  still  an  o|)en  (|Uestion  as  to  whether  the  eharaeter- 
i.sties  are  nni"ailini;ly  diat>;nostic  of"  the  special   form  of  jrrowth. 

It  is  not  in  place  here  to  describe  the  chemical  tests  to  which  the 
fluid  may  be  subjected  or  to  broach  the  subject  of  the  "  ovarian  cell." 
Such  (piestions  will  be  discussed  elsewhere.  The  jjoint  at  issue  will 
ordinarily  lie  between  ovarian  cysts,  intrali*!:amentous  cysts,  and  fibro- 
cystic j^rowths  of  the  uterus.  Cystic  growths  of  the  liver  and  kidney 
may  usually  be  recognized  under  the  microscope  by  the  presence,  in  the 
first  instance,  of  degenerated  liver-cells  and  cholesterin  ;  in  the  second 
instance,  of  urea  or  uric  acid.  PIvdatid  cysts  are  recognized  through 
the  characteristic  booklets  of  the  parasite.  Finally,  as  pointed  out  by 
Munde,  the  aspirator  needle  will  often  reveal  to  us  the  reason  why  an 
old  pelvic  cellulitis  will  not  yield  to  routine  treatment,  by  withdrawing 
a  small  (|uantity  of  ])us  situated  so  deeply  as  not  to  yield  fluctuation 
to  the  examiniuo;  finuer. 


GENERAL  CONSIDERATION  OF  GYNECOLOG- 
ICAL SURGERY. 


By  E.  C.  DUDLEY,  A.  B.,  M.  D., 

Chicago. 


Antisepsis. 

I:n'ASMUCH  as  the  minor  gynecological  operations  which  are  per- 
formed for  the  relief  of  maladies  that  are  not  often  fatal,  nor  even 
always  disabling,  have  occasionally  been  followed  by  sepsis,  metro- 
peritoneal  inflammations,  cellulitis,  and  sometimes  even  by  death, 
therefore  the  practitioner  in  the  hope  of  spontaneous  recovery  has 
often  preferred  palliative  and  temporizing  measures,  however  unprom- 
ising, to  the  exclusion  of  surgical  measures,  however  rational.  But  the 
application  of  the  antiseptic  principle  now  renders  the  minor  gyneco- 
logical operations  and  office  manipulations  comparatively  free  from 
danger. 

Prophylaxis. — The  essential  object  of  antiseptic  surgery  is  cleanli- 
ness— not  sesthetic  but  surgical  cleanliness.  To  secure  and  to  maintain 
surgical  cleanliness  many  antiseptic  materials  have  been  employed,  of 
which  the  most  generally  approved  is  carbolic  acid,  but  the  solutions 
should  be  made  with  great  care,  lest  a  part  of  the  acid  settle  to  the 
bottom  of  the  vessel,  and,  being  pure  acid  instead  of  solution,  produce 
a  serious  burn  when  applied.  The  addition  of  10  per  cent,  of  glycerin 
to  the  pure  acid  renders  it  more  easily  soluble.  A  saturated  solution 
of  boric  acid  or  a  3  per  cent,  solution  of  salicylic  acid  is  free  from 
caustic  properties  and  is  an  excellent  antiseptic.  Permanganate  of 
potash  in  solution  decomposes  so  readily  than  it  is  unreliable  for  anti- 
septic purposes.  Solutions  of  corrosive  sublimate  may  be  conveniently 
made  by  mixing  a  10  per  cent,  alcoholic  solution  with  sufficient  water  to 
make  the  required  strength,  which  should  be  from  1  :  1000  to  1  :  10,000. 
The  stronger  solutions  are  adapted  to  the  cleansing  of  the  hands  and 
other  cutaneous  surfaces,  and  the  weaker  for  washing  the  sponges  dur- 
ing operations.  Corrosive  sublimate  tarnishes  metallic  instruments  and 
destroys  their  plating,  but  has  the  advantage  of  being  odorless  and  in 
ordinary  solutions  of  not  roughening  the  skin.  It  is  a  most  reliable 
germicide. 

328 


.\.\risi:rsis.  ,",2f) 

Tlic  soap,  ^I\  I'ci'iii,  \;i>t'Iiiic,  or  nil  wliidi  i-;  ii-iiiilly  kept  l»\'  the 
(»pci';it(ii"'s  (;il)lc  In)'  liiWriralimi  n|"  the  linger-  and  in-trimiciils  iiia\'  Itc 
coiitainiiiati'd  with  ii'oimrilKral  uv  dllitr  viiMis,  ami  iiiav  iliiis  Itccoinc  a 
nuMliiiiii  ot"  iulc'ction.  Ni-itlicr  tlic  tiii>i,i'rs  nor  tlic  spi'ciihini,  tiicrcforc, 
slioiild  ))('  hi-oiiuiit  in  <'<>ntact  with  the  luln-icMtinji-  sui)stanc('  iiiilcss  they 
hi'  f'ri'c  I'roni  vat;inal  ami  ntlur  sccrrtions.  'I'lic  caincrs- hair  pencil 
brush  and  the  spi>iit!;c'  faunut  he  properly  cleansed,  and  they  are  there- 
lore  unfit  lor  rcp(>ated  use.  Absorbent  cotton  wound  u|ion  an  a|)plieator 
oi-  stick  or  lii-aspcd  by  dressiuji- forceps  may  I)e  used  for  [)urp(»ses  of 
niedicatioii  or  for  wipini>;  out  the  va<2;iua,  and  should  then  be  destroyed. 
No  special  cleausiuii-  of  the  vulva  aiul  vagina  is  re(|uii'ed  i'ny  ordinary 
oflice  manipulation  of  these  ori;aus  except  the  vaginal  douche,  which 
the  patient  usually  takes  before  a})plying:  for  treatment.  If  the  intra- 
uterine cavity  is  to  be  instrumentally  or  di<!:itally  explored  or  treated,  it 
is  best  to  wipe  out  the  vagina  with  dry  absorbent  cotton,  and  then  with 
absorbent  cotton  saturated  with  a  5  per  cent,  solution  of  carbolic  acid 
in  olvcerin  or  with  a  solution  of  corrosive  sublimate,  1  :  2000.  By  this 
means  the  endometrium  is  protected  against  the  entrance  of  septic  mat- 
ter, which  otherwise  might  be  carried  in  from  the  vulva  or  vagina  on 
the  instruments.  But  previous  to  any  surgical  operation  on  the  genital 
tract  or  in  the  abdomen  the  field  of  operation  and  Mhatever  may  possil)ly 
be  brought  in  contact  therewith  should  be  rendered  surgically  clean,  and 
so  maintained  throughout  the  operation  and  during  convalescence.  This 
treatment  relates  alike  to  the  most  trifling  and  to  the  most  severe  opera- 
tions, because  the  former  are  by  no  means  free  from  danger  of  fatal 
sepsis,  and  because  a  performance  of  seemingly  minor  importance  in 
the  beginning  may  end  accidentally  or  purposely  in  opening  the 
abdomen  or  in  some  other  capital  operation.  Therefore,  the  vulva 
should  be  thoroughly  and  repeatedly  "U'ashed  with  tar  soap  and  water, 
and  the  hot  vaginal  douche  should  be  applied  twice  a  day  during  the 
week  previous  to  operation,  each  douche  to  contain  a  small  quantity 
of  castile  or  tar  soap,  except  the  last  to  be  given  just  before  operation, 
which  should  be  a  solution  of  corrosive  sublimate,  1  :  4000. 

The  ordinary  ]iractice  of  simply  cleansing  the  instruments  after  each 
examination  or  treatment  in  water  or  soap  and  water  is  inadequate  and 
unsafe.  ^T]sthetic  cleanliness  does  not  absolutely  destroy  virus  and  pre- 
vent its  instrumental  conveyance  from  one  patient  to  another.  Perfect 
surgical  cleanliness,  however,  may  be  secured  in  the  following  manner: 
First,  let  the  instruments  be  carefully  washed  in  the  ordinary  way,  with 
hot  water  and  soap  ;  then  let  each  instrument  be  thoi'oughly  ^viped  over 
Avith  absorbent  cotton  saturated  with  carbolic  acid  and  glycerin,  equal 
parts.  To  do  this  easily  two  strong  forceps  are  needed — tme  in  the 
left  hand  to  hold  the  instrument,  and  the  other  in  the  right  to  hold  the 
cotton.     The  instruments  thus  moistened  with  acid  are  now  thrown  into 


330    GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

a  pan  containing  water  which  has  been  boiled  and  filtered.  This  water 
and  the  adherent  acid  make  an  excellent  solution  in  which  to  keep 
the  instruments  during  an  operation.  If  the  instruments  have  been 
unusually  exposed  or  if  they  are  to  be  used  in  the  abdomen,  it  is  well 
to  render  the  disinfection  absolute  by  passing  them  slowly  through 
the  flame  of  a  Bunsen  burner  or  of  a  spirit-lamp  before  applying  the 
carbolic  acid. 

The  cleansing  and  disinfection  of  the  operator's  hands  and  nails  even 
after  ordinary  digital  examination  are  imperative,  not  only  to  guard 
against  the  carrying  of  poison  to  the  patient,  but  to  prevent  self-inocu- 
lation of  specific  or  non-specific  virus  through  some  abrasion  upon  the 
hand. 

The  annoying  presence  of  fecal  matter  during  a  surgical  operation 
and  its  possible  septic  results  may  be  avoided  by  giving  the  preparatory 
cathartic  so  early  that  its  action  will  be  complete  on  the  day  before.  In 
order  to  render  the  sponges  free  from  foreign  and  septic  matter,  first 
thoroughly  beat  and  wash  out  all  the  sand  (this  may  require  hours  of 
patient  labor) ;  then  soak  them  over  night  in  dilute  hydrochloric  acid, 
to  dissolve  out  calcareous  matter ;  and  after  washing  out  the  acid,  the 
sponges,  which  will  then  be  much  softer  and  more  elastic,  may  be  put 
away  in  self-sealing  fruit-jars  containing  a  5  per  cent,  solution  of  car- 
bolic acid  or  a  1  :  2000  solution  of  corrosive  sublimate,  the  solution  to 
be  changed  every  week.  The  boiling  of  sponges  is  an  excellent  anti- 
septic measure,  but  it  causes  great  shrinkage  and  hardening,  and  very 
much  lessens  their  absorbent  qualities. 

The  ligature  and  suture  silk  may  be  made  thoroughly  aseptic  by 
boiling  it  for  five  minutes  in  pure  carbolic  acid,  and  then  for  twenty 
minutes  in  a  5  per  cent,  solution.  The  best  braided  silk  thus  treated 
may  be  kept  for  months  without  injury  in  small  wide-mouthed  bottles 
well  corked,  or  in  special  ligature  bottles,  containing  a  5  per  cent, 
solution  of  carbolic  acid.  The  braided  silk  is  preferable  to  the  twisted, 
because  the  latter  is  usually  injured,  sometimes  destroyed,  by  boiling  in 
pure  carbolic  acid. 

The  field  of  operation,  rendered  aseptic  in  the  manner  already 
described,  may  be  kept  so  during  the  operation  if  attention  be  given 
to  the  cleanliness  of  hands,  sponges,  instruments,  and  other  appliances. 
The  occasional  irrigation  of  the  wound  during  the  operation,  and 
especially  Avhile  it  is  being  closed  with  sutures,  is  of  great  value  to 
ensure  perfect  contact  of  the  wound  surfaces  without  the  intervention 
of  blood  or  other  foreign  bodies. 

The  object  of  after-treatment  is  to  maintain  cleanliness.  At  the  end 
of  the  operation  all  particles  of  tissue  and  clots  of  blood  should  be 
removed  and  the  parts  thoroughly  cleansed  by  the  hot-water  vaginal 
douche,  which  should  be  repeated  every  twelve  hours  until  several 


ANTfSEPSrS.  331 

(lavs  aflcr  the  rciii(i\':il  of  the  -iiliircs.  Aft<'r  njici-atlon--  on  the  exter- 
nal p'liitalia  the  tlitiicln'  should  al-o  he  t;-iv('n  alter  each  cvaciiation  of 
the   howfls  or   hhiddcr. 

Schrocdcr  and  (tthci'  (Jci-nian  f»|)ci-ators  ('ni])loy  con.-tant  ini;ration 
(luring-  operation.  This  re(|nires  the  j)atient  to  he  in  the  dorsal  posi- 
tion, and  when  the  o|)eration  is  intrava;:;inal  neeossitatos  the  n.se  of 
Simon's  s|)eeninni.  (See  Fi*;-.  139.)  Dr.  Engelmann  of  St.  Louis,  in 
a  eonununieation  to  the  American  Medical  Association,  1885,  .stron<rly 
advocates  this  method,  which  he  has  improved  hy  the  em])loyment 
of  hot  antiseptic  solutions  foi-  the  irrigatinir  fluid.  He  uses  a  hot 
solution  of  corrosive  suhlimate,  1  :  2000,  or  a  2  per  cent,  .solution 
of  carbolic  acid  made  with  boiled  and  filtered  water.  A  special 
assistant,  standing  somewhat  to  the  rear  and  to  the  left  of  the  ope- 
rator, manages  the  douche.  A  fountain  syringe  or  bucket  contains 
the  fluid,  which  is  c<jnducted  to  the  wound  through  a  rubber  tube  five 
feet  long,  supplied  m  ith  nozzle,  and  a  stopcock  to  be  controlled  by  the 
thumb  of  the  hand  which  holds  the  nozzle.  The  opening  in  the  end 
of  the  nozzle  is  one-eighth  of  an  inch  in  diameter.  The  bucket,  placed 
about  three  feet  above  the  field  of  operation,  gives  enough  force  to  the 
stream  to  keep  all  blood  constantly  washed  away,  which  is  to  be  done 
with  an  even,  steady  current  directed  just  above  the  field,  and  regulated, 
without  splashing,  according  to  the  amount  of  hemorrhage.  The  tem- 
])erature  of  the  irrigating  fluid  should  be  about  120°  F.  The  hand 
which  holds  the  speculum  as  the  water  flows  over  it  would  recognize 
excessive  heat  Avhile  the  patient  is  under  ether.  The  external  geni- 
talia may  be  guarded  Avith  lard  as  an  additional  safeguard  against 
scorching.  The  urethra  is  especially  sensitive  to  hot  water,  and  should 
therefore  be  avoided  in  directing  the  stream.  The  hot  douche  by  rea- 
son of  its  hemostatic  and  cleansing  properties  lessens  the  flow  of  blood 
and  keeps  the  parts  clean,  and,  inasmuch  as  it  removes  all  necessity 
for  sponging,  it  shortens  the  time  of  the  operation.  The  antiseptic 
value  of  the  hot  douche  is  proved  by  the  fact  that  its  advocates  suc- 
cessfully employ  silk  sutures,  which  with  the  ordinary  methods  of 
operation  often  cause  suppuration  and  failure  of  union. 

After  the  sutures  have  been  tied  the  wound  is  to  be  dried  Avith 
absorbent  cotton  dusted  with  iodoform  and  covered  with  iodoformed 
cotton  or  gauze,  to  be  removed  in  four  days ;  then  the  parts  should  be 
again  dried,  dusted,  and  repacked.  Two  or  three  dressings  may  be 
required  before  the  removal  of  the  sutures,  after  that  but  one.  Opera- 
tions on  the  external  genitals,  however,  necessitate  the  frequent  renewal 
of  at  least  a  part  of  the  dressing  to  provide  for  the  action  of  the  bowels 
and  for  micturition  ;  but  in  such  cases  the  hot-water  vaginal  douche 
repeated  two  or  three  times  a  day  would  be  preferable  to  the  dry  anti- 
septic dressing. 


332    GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

The  leading  features  of  the  German  method,  as  modified  by  Engel- 
mann,  are  Simon's  speculum,  the  dorsal  decubitus,  the  hot  antiseptic 
douche,  the  absence  of  sponges,  and  the  simplicity  of  after-treatment. 
The  advantages  claimed  are  greater  cleanliness,  simplicity,  and  speed. 

Treatment  of  Septic  Gynecological  Wounds. — Certain  nat- 
ural conditions  are  favorable  to  the  healing  of  wounds  on  the  cervix 
and  vagina.  The  opposite  vaginal  wall  in  contact  with  the  wound 
excludes  the  air  and  acts  as  a  compress,  and  the  vagina  itself  is  an 
excellent  substitute  for  the  drainage-tube.  But  the  conditions  after 
intra-uterine  operations  are  less  favorable,  because  the  uterine  canal  is 
at  an  acute  angle  to  the  long  axis  of  the  vagina,  and  the  cervical  por- 
tion of  this  canal,  naturally  narrow,  may  have  become  narrower  from 
disease.  Therefore,  secretions  accumulating  in  the  uterine  cavity  may 
not  be  easily  expelled  by  force  of  gravity  or  by  uterine  contractions^ 
but,  on  the  contrary,  may  be  confined  and  become  infectious  with, 
inflammatory  and  sej^tic  results.  The  condition  simulates  that  of  a 
deep  abscess  at  the  end  of  a  long  and  tortuous  sinus.  On  general  prin- 
ciples the  therapeutic  indication  is  clearly  to  cleanse  the  cavity  and  to 
keep  it  as  nearly  aseptic  as  possible  by  irrigation.  Although  this  treat- 
ment is  often  followed  by  excellent  results,  it,  unfortunately,  is  not  free 
from  grave  objections,  and  often  proves  even  more  dangerous  than  the 
disease.  Sometimes  the  stimulating  presence  of  the  irrigating  fluid  or 
of  the  cannula  through  which  it  is  injected  causes  the  uterine  walls  to 
contract  upon  the  instrument  so  forcibly  that  the  return  flow  is  impeded^ 
and  the  fluid  may  pass  into  the  Fallopian  tubes,  especially  if  they  have 
been  dilated  by  disease,  with  grave  inflammatory  or  septic  results; 
moreover,  intra-uterine  injections  without  invasion  of  the  Fallopian, 
tubes  have  many  times  been  followed  by  painful  uterine  contrac- 
tions, pelvic  inflammation,  and  death.  These  injections  are  there- 
fore only  to  be  employed  when  the  canal  throughout  is  open  or  can  be 
made  sufiiciently  open  to  permit  free  outflow,  and  even  then  with  great 
caution.  To  guard  against  obstruction  of  the  outflow  by  contraction 
of  the  uterus  upon  the  instrument  it  is  necessary  to  use  some  one  of 
the  double  uterine  catheters — Molesworth's,  Nott's,  or  Bozemann's,  for 
example — which  have  been  specially  devised  for  the  purpose,  and 
which  are  similar  in  construction  to  Skene's  double  catheter  for  irri- 
gation of  the  bladder.  Preparatory  dilatation  may  be  required  before 
intra-uterine  irrigation  can  be  safely  undertaken. 

The  treatment  of  septic  wounds  in  the  uterine  cavity  involves  some 
of  the  vexed  questions  in  gynecology.  It  is  often  difficult  to  determine 
whether  the  disease  is  confined  to  the  uterus  or  whether  the  wounded 
surface  has  not  rather  served  as  an  avenue  through  wliich  bacteria 
may  have  passed  to  the  pelvic  cellular  tissue  or  to  the  peritoneum,  and 
there  produced  results  which  not  only  could  not  be  reached  by  intra-- 


wjii:y  TO  <>i'i:i:.\ri:.  3.33 

iilci'iiic  trcMtiiiciit,  lull  wliirli  -iirli  trc;iliiiciit  iiiiL''lil  <'\<'ii  I'Mij^^-cnitc. 
'I'lic  |):ittiloiis  cdiKlitioM  (if  tlic  utcriiu'  canal  iti  inicrpcral  can's  makes 
the  oi'iiaii  easily  aixl  safely  accessilile,  and  the  ti'eatnieiit  tliereiorc  more 
effect i\-e.  The  most  eifieicnt  aiiti>e|tsis  in  |Mirely  surgical  gynecology 
is  o'cneralK'    prnpliyiactie. 

Opium,  Quinine,  and  Ice. 

In  addition  to  antise])sis  certain  other  precautions  against  cellnlitis, 
|)t'ritonitis,  and  metritis  slionld  he  enforced,  especially  in  cases  jiredis- 
posed  hy  a  pi'cvions  attack.  Prepai'atorv  to  operation  the  ])atient  mav 
he  fortiHed  hy  fnll  doses  of  (piinine,  and  f(»r  two  or  three  days  after  the 
operation  this  sh< mid  he  continued  and  sn])plemented  with  o|)iimi  to  con- 
trol pain,  and  with  the  icc-hladdcr  over  the  hyj)ogastrium.  Tiic  thin  gum 
rul)l)cr  ice-l)ladder  is  most  convenient,  but  the  ordinary  sheet  irum  rubber 
two  feet  square,  such  as  dentists  use  for  the  rubber  dam,  may  be  substituted 
by  gathering  up  its  sides  and  corners  above  tiie  ice  and  tying  them  with 
strong  twine.  To  prevent  the  annoying  condensation  of  water  on  the 
outside  of  the  rubber  bag  another  piece  of  rubber  or  oiled  silk  should 
be  Avrap})ed  about  it.  Great  reliance  may  be  placed  upon  opium, 
quinine,  and  ice,  not  only  for  prophylaxis  against  inflammation,  but 
also  as  a  remedy  in  the  acute  stage.  Ice  is  much  more  certain  in  its 
results  than  the  time-honored  and  conventional  hot  flaxseed  poultice. 

When  to  Operate. 

It  may  be  urged  as  a  general,  though  by  no  means  a  universal, 
proposition  that  the  female  genitalia  should  be  exempt  from  all  inter- 
ference during  menstruation.  For  example,  it  Avould  be  unwise  to 
o])erate  for  laceration  of  the  cervix  or  perineum  or  for  vesico-vao-inal 
fistula  during  menstruation.  But  when  menstruation  is  so  long  con- 
tinued or  so  profuse  as  to  endanger  health  or  life,  immediate  inter- 
ference may  be  demanded.  Indeed,  it  has  not  been  proved  that  opera- 
tions are  decidedly  more  dangerous  in  the  menstrual  than  in  the  inter- 
menstrual period.  The  presence  of  the  menstnial  fluid,  hoAvever,  is 
unfavorable,  though  not  usually  disastrous  to  union  by  first  intention. 
An  operation  if  performed  immediately  upon  the  cessation  of  the  flow 
might  cause  it  to  reappear,  and  if  too  near  to  the  anticipated  period  it 
might  excite  premature  menstruation.  The  best  time,  therefore,  is 
between  the  third  day  after  the  cessation  of  one  period  and  the  tenth 
<lay  before  the  anticijiated  appearance  of  the  next. 

The  question  of  primary  or  sec(jndary  operations  after  the  })uerperal 
lacerations  has  been  much  discussed.  Emmet's  operation  for  laceration 
of  the  cervix  should  l)e  delayed  until  after  the  puerperium,  though  a 


334   GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

few  cases  of  the  immediate  operation  successfully  performed  have  been 
reported.  For  laceration  of  the  perineum,  however  extensive,  the  im- 
mediate operation  is  desirable  for  two  reasons  :  The  torn  parts  can  be 
accurately  adjusted  to  their  former  relations,  which  is  almost  impos- 
sible in  the  secondary  operation ;  and  the  operation  if  well  performed 
generally  results  in  union,  and  thereby  protects  the  patient  against  septic 
infection  through  the  torn  surfaces.  The  writer  therefore  would  advise 
the  primary  operation  of  perineorrhaphy  even  as  late  as  two  days  after 
delivery.  He  has  repeatedly  operated  on  the  second  and  third  days,  and 
once  on  the  ninth,  and  with  scarcely  an  exception  the  delayed  operation 
has  resulted  in  satisfactory  union.  If,  however,  the  primary  operation 
has  been  delayed  for  a  number  of  days,  it  is  best  before  introducing  the 
sutures  to  denude  with  the  curved  scissors  a  narrow  strip  all  around  the 
torn  surfaces,  in  order  that  fresh  surfaces  may  be  brought  together.  A 
delay  of  a  few  hours  after  delivery  ensures  greater  freedom  from  capil- 
lary oozing  from  the  torn  surfaces,  which  sometimes  occurs  after  closure 
of  the  wound  and  which  may  prevent  union ;  and  moreover,  if  anaes- 
thesia be  required,  it  is  better  to  wait  for  permanent  retraction  of  the 
uterus,  otherwise  the  anaesthetic  may  cause  relaxation  and  consequent 
uterine  hemorrhage. 

It  is  the  duty  of  the  accoucheur  at  the  close  of  the  puerperium  to 
examine  the  uterus,  vagina,  and  perineum,  and  to  repair  any  puerperal 
laceration  or  injury  before  its  evil  results  have  developed.  Operations 
may  be  necessary,  therefore,  during  lactation.  The  child  should  be 
kept  from  the  breast  only  until  the  mother  has  fully  recovered  from 
the  anaesthetic. 

Operations  during  pregnancy  should  not  be  undertaken  save  in  rare 
cases  in  which  the  life  or  health  of  mother  or  child  is  seriously  in- 
volved. Matthew  D.  Mann^  of  Buffalo  has  collected  90  cases  in  which 
gynecological  operations  have  been  performed  on  pregnant  women ;  of 
these,  abortion  followed  from  the  operation  in  20  cases ;  and  of  these 
20,  only  4  died.  His  conclusions,  which,  as  he  says,  may  or  may  not 
be  verified  by  further  observations,  are  as  follows : 

"1.  Pregnancy  is  not  so  decidedly  a  bar  to  operation  on  the  pelvic 
organs  as  is  generally  supposed.  The  results,  however,  vary  with  the 
operation  and  the  organ  operated  upon. 

"  2.  Union  of  denuded  surfaces  is  the  rule,  and  the  cicatricial  tissue 
formed  during  the  earlier  months  of  pregnancy  is  strong  enough  to 
resist  the  shock  of  labor  at  term. 

"  3.  Operations  on  the  vulva  involve  very  little  danger  either  to 
mother  or  child. 

"  4.  Operations  on  the  vagina  are  likely  to  cause  severe  hemorrhages, 
but  are  not  otherwise  dangerous. 

'  Gynecological  Transactions,  1883,  vol.  vii. 


wifi:\  TO  ()j'Kn.\TK.  335 

"5.  X'cncrciil  \\;irts  ;iii(l  vcp'talinii-;  oi"  Iari:<'  >!/•<■  mikI  noti-.-Nphilitic 
arc  Ix'st  ti'catcd  l)v  i'ciii(i\al,  w  lictlici'  tlicy  Dcciir  in  (he  vaj^ina  or  arc 
(•(»ii(iiu'(l   t(»  (lie  vulva. 

"  ().  Applications  of  nitrate  ot"  silvci-  and  astrinj^ents  of"  lliis  class 
niav  lu'  made  with  safety  to  the  vagina  and  cervix.  Din'nsihlc  jutisons, 
like  earholic  acid  or  iodine,  should  not  he  used  pure  or  in  stronjr  sohi- 
tions  for  such   applications. 

"7.  Operations  iijxin  the  hhidder  and  urethra  are  not  dangerous  or 
likelv   to   l)e   followed   l>y   abortion. 

**  8.  Operations  on  the  rectum  involving  the  sphincter  ani,  even  if 
slight   in  their  character,  arc  dangerous. 

"9.  The  operation  for  vcsico- vaginal  fistula  sh(»uld  not  he  under- 
takiMi  during  pregnancy,  as  the  dangers  of  hemorrhage  and  al)orti<»n 
are  considcrahle. 

'*10.  Plastic  operations  on  the  cervix  and  perineum  may,  if  neces- 
sary, I)e  undertaken  in  the  earlier  months  of  pregnancy  with  a  fair 
])rospect  of  success,  and  with  a  good  chance  that  the  results  may  not 
be  impaired  by  labor. 

"11.  Small  polypi  of  the  cervix  may  best  be  treated  by  torsion  or 
strong  astringents.     If  cut,  there  is  some  danger  of  abortion  following. 

"  12.  Large  polypi  may,  if  causing  hemorrhage,  be  removed  at  once, 
with  a  fair  chance  of  good  results.  If  not  doing  any  harm,  then  re- 
moval is  best  left  until  near  the  close  of  pregnancy. 

"13.  Cancer  of  the  cervix  discovered  during  pregnancy  should,  if 
possible,  be  removed  at  once." 

The  possible  necessity  implied  in  the  tenth  proposition,  which  would 
demand  a  plastic  operation  on  the  cervix  or  perineum  of  a  pregnant 
woman,  must  be  extremely  rare. 

Two  or  more  gynecological  operations  may  safely  be  undertaken  at 
one  time  if  the  patient  be  in  good  condition,  if  the  operations  do  not 
conflict  one  with  the  other,  and  if  the  operator  be  rapid  and  dexterous. 
Trachelorrhajiliy  and  perineorrhaphy,  and  sometimes  trachelorrhaphv, 
anterior  elytrorrhaphv,  and  perineorrhaphy,  are  permissible  at  one  sit- 
ting. Trachelorrhaphy  and  the  operation  for  hemorrhoids  are  often 
combined.  The  author  has  frequently  operated  for  laceration  of  the 
perineum  and  for  hemorrhoids  at  the  same  time,  and  always  with  satis- 
factory results.  When  operations  on  the  cervix  and  anterior  vaginal 
wall  are  combined  with  perineorrhaphy,  the  cervical  and  vaginal 
sutures  must  not  be  removed  until  the  fourth  week,  when  the  peri- 
neal union  will  be  firm  enough  to  withstand  moderate  distension  of 
the  vulva  by  the  speculum.  Trachelorrhaphy  should  not  be  combined 
with  curetting,  dilatation,  incision,  or  with  any  other  intra-uterine  one- 
ration,  because  operations  on  the  uterus,  especially  on  the  interior  of  the 
uterus,  are  peculiarly  liable  to  be  followed  by  mctro-peritoncal  inflam- 


336   GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

mation  and  sepsis,  and  because  trachelorrhaphy  would  interfere  with 
free  drainage  of  the  secretions  from  an  intra-uterine  wound,  and  would 
thereby  increase  the  danger.  Moreover,  an  accumulation  of  coagulated 
blood  might  be  forced  by  uterine  contraction  through  the  closed  cervix 
and  thereby  destroy  the  union. 

During  epidemics  of  infectious  or  contagious  diseases  operations  on 
the  female  genitalia  are  prohibited  by  the  increased  liability  to  sepsis 
and  pelvic  inflammations,  and  if  possible  should  be  avoided ;  nor 
should  they  be  undertaken  while  the  patient  is  suffering  from  any 
acute  disease.  The  immediate  operation  of  perineorrhaphy,  for  exam- 
ple, usually  fails  if  closely  followed  by  inflammation  of  the  mammary 
gland. 

The  occasional  necessity  for  surgical  interference  during  the  acute 
stage  of  pelvic  inflammation  justly  excites  the  greatest  fear,  yet  the 
dread  of  such  interference  is  sometimes  exaggerated.  The  septic  and 
inflammatory  results  of  a  gangrenous  intra-uterine  fibroid  or  of  the 
secundines  of  an  abortion  might  be  vastly  more  dangerous  than  the 
operation  for  their  removal. 


Preparatory  Treatment. 

Syphilis,  gout,  rheumatism,  Bright's  disease,  purpura,  or  faulty 
nutrition  from  any  cause  may  prevent  union,  and  may  therefore  require 
■constitutional  tonic  and  hygienic  treatment  preparatory  to  operation. 

In  the  presence  of  a  periuterine  exudate  and  thickening,  with  fixa- 
tion of  the  uterus,  which  always  persist  for  a  variable  time  after  pelvic 
cellulitis  and  peritonitis,  it  is  safer  to  defer  all  surgical  operations  until 
time  and  treatment  have  reduced  the  products  of  inflammation  and  the 
periuterine  tenderness  to  a  minimum,  and  until  the  mobility  of  the 
uterus  has  returned.  While  the  slightest  trace  of  a  former  cellulitis  or 
peritonitis  exists,  an  operation,  however  trivial,  may  result  in  a  fatal 
recurrence  of  the  inflammation.  In  such  conditions,  therefore,  it  is  a 
safe  rule  to  delay  operation.  Dr.  H.  C.  Coe,^  on  the  other  hand,  has 
shown  that  old  chronic  thickenings  are  not  always  the  material  products 
of  inflammation,  but  may  be  the  simple  result  of  cicatricial  contractions 
following  local  peritonitis,  and  that  they  are  not  a  positive  contraindi- 
cation to  operation. 

The  objects  of  local  preparatory  treatment  are  not  only  to  remove 
the  products  of  inflammation,  but  to  render  the  field  of  operation 
as  free  from  disease  as  possible.  A  lacerated  cervix  in  a  state  of 
granular  erosion  and  cystic  degeneration,  or  a  vesico-vaginal  fistula 
encrusted  with  phosphatic  deposits,  would  not  give  the  greatest  promise 

^  "  Transactions  of  the  Woman's  Hospital  Alumni  Association,"  American  Journal 
ef  Obstetrics,  February,  1886. 


orL'iiA  rios-  T.  I  /;/.  /•;.  337 

of  imioii  l)y  first  intention.  'IMicrcforf,  tlic  liot-watcr  vaginal  (IomcIk-, 
iotlinc  applications,  tlic  daiK'  lainpnn  of  ali<oi'lniit  cotton  >alnra(c<l  with 
pure  ijlvccrin  or  olvccrin  coiiiltimd  wiih  aliini,  laniiin,  or  iodolorni,  ami 
tlio  pnnctiirini;-  <if"  rctcnt ion-cysts,  may  Wc  i('<|nircil  lor  many  weeks 
hcforc  the  cervix  is  in  a  condition  i;iv(»ral)Ie  foi'  union.  The  fistnla 
mav  rc(|iiire  lon<i'  and  patient  vaiiinal  dilatation  hcforc  its  edges  can 
even  he  approximated.  But  sometimes  the  induration,  lixation,  and 
])eriiiterino  tenderness  do  not  yield  to  the  usual  treatment  of  hot  water, 
jrlyeerin  tampons,  iodine,  and  rest ;  numerous  eases  of  granular  erosion 
of  the  cervix  are  not  influenced  by  topical  applications,  liowevcr  long 
continued.  I  n  some  cases  neither  the  general  nor  the  local  condition  can 
l)c  materially  improved  except  by  a  successful  plastic  operation  ;  then 
the  gentle  and  i-aj)id  manijndations  of  an  exj)ert  o|)erator  may  result  in 
less  injury  to  the  nervous  system  of  a  debilitated  patient,  in  greater 
freedom  from  inflammatory  reaction,  and  in  more  satisfactory  union, 
than  an  inexperienced  operator  could  secure  under  more  favorable 
conditions. 

Emmet  recommends  a  hot  vaginal  douche  of  120°  F.  to  be  given 
for  thirty  minutes  just  before  an  operation.  This  is  for  the  double 
purpose  of  cleansing  the  vagina  and  of  so  constricting  the  capillaries 
that  hemorrhage  from  denuded  surfaces  may  be  partially  prevented. 
Just  before  giving  the  auresthetic  the  operator  should  make  a  careful 
examination  by  conjoined  manipulation  to  satisfy  himself  that  the 
patient  is  free  from  cellulitis  or  peritonitis  which  may  have  become 
active  since  the  examination. 

The  dress  of  the  patient  should  he  such  as  would  ordinarily  be  used 
in  bed,  and  should  be  supplemented  by  open  drawers,  stockings,  and  a 
flannel  blanket.  The  night-dress  may  be  drawn  up  about  the  waist  to 
protect  it  from  blood,  and  a  large  folded  towel  or  sheet  may  be  placed 
under  the  patient's  hips  to  keep  the  blanket  which  covers  the  table  from 
being  soiled. 

Operation-Table, 

The  operation-table  should  be  approximately  48  inches  long,  24 
inches  wide,  and  27  inches  high.  The  ordinary-  kitchen  table  or 
narrow  dining-table,  with  the  leaves  down,  covered  with  a  blanket  or 
quilt,  fulfils  all  the  requirements.  Greater  length  is  objectionable, 
l)ecause  when  the  thighs  are  flexed  and  the  hips  drawn  toward  the 
operator,  the  head  should  be  near  to  the  ana?sthetizcr,  who  stands  at 
the  end  of  the  table  opposite  the  operator.  A  chair  or  stand  may 
be  placed  temporarily  for  the  feet  while  the  patient  is  being  etherized. 
The  bed  is  too  low,  too  yielding,  and  too  large  for  operative  purjioses. 
An  operation-table  specially  devised  for  hospital  practice  should  have 
attached  at  the  end  a  coj)pcr  or  porcelain  basin,  into  which  the  Avater 
Vol.  I.— 22 


338    GEXEEAL   COXSIDEEATION  OF  GYNECOLOGICAL  SURGERY. 

may  flow  should  it  he  necessary  to  wash  out  the  bladder  or  vagina 
during  operation  or  to  operate  under  the  hot  antiseptic  douche. 


Anesthesia. 

The  principles  which  apply  to  aneesthesia  for  surgical  purposes  in 
general  apply  also  without  change  for  the  operations  of  gynecology. 
Sulphuric  ether  is  safer  than  chloroform,  and  should  therefore  be  pre- 
ferred, however  short  the  operation  may  be.  In  exceptional  cases 
complete  anaesthesia  by  ether  proves  \ery  difficult  or  impossible. 
The  Vienna  mixture,  composed  of  one  part  alcohol,  two  parts  chloro- 
form, and  three  parts  ether,  may  then  be  substituted  until  anaesthesia  is 
complete,  when  the  ether  should  be  resumed.  Emmet  has  pointed  out 
that  when  the  kidneys  are  not  sotmd,  chloroform  is  much  safer  than 
ether,  and  should  therefore  always  be  used  under  such  conditions. 

The  hydrochlorate  of  cocaine  used  hypodermically  at  or  as  near  as 
possible  to  the  field  of  operation,  in  doses  of  one  half  grain  or  more, 
produces  perfect  local  anaesthesia  of  short  duration,  which  may  be  pro- 
longed by  repeating  the  dose.  Many  of  the  minor  gynecological  opera- 
tions, such  as  curetting,  dilatation  of  the  uterine  canal,  division  of  the 
cervix,  and  unilateral  trachelorrhaphy,  may  in  this  way  be  performed 
with  little  or  no  pain.  The  maximum  dose  of  cocaine  has  not  been 
fixed,  but  it  has  been  given  in  doses  of  several  grains.  As  a  local 
anaesthetic  it  is  more  reliable  when  used  h^-podermically  than  when 
brushed  over  a  mucous  or  cutaneous  surface.  Intolerance  by  idiosyn- 
crasy has  occasionally  been  obser\^ed,  but  the  possible  dangers  of  the 
drug  are  unknown.  A  4  per  cent,  solution  sprayed  over  the  Schnei- 
derian  membrane  has  caused  alarming  symptoms. 

Materials  for  Sutures. 

Silk,  catgut,  and  silver  ^  are  the  materials  most  commonly  employed 
for  sutures  in  gynecological  operations ;  each  has  its  peculiar  advantages 
and  disadvantages  ;  neither  is  universally  to  be  preferred. 

Silh. — The  braided  absorbs  less  moisture  and  is  superior  to  the  t^- isted 
silk  both  for  sutures  and  ligatures.  The  best  braided  silk  is  that  of 
Archibald  Turner  &  Co.  Xo.  7  is  suitable  for  sutures  in  plastic 
operations  on  the  perineum,  vagina,  and  cervix,  but  it  is  too  heavy  for 
the  ligation  of  small  vessels.  Silk  sutures  and  ligatures,  if  rendered 
thoroughly  aseptic  according  to  the  directions  given  in  the  section  on 
Gynecological  Antisepsis,  will  remain  aseptic  for  four  or  five  days,  and 

^  Silver-plated  copper-wire,  -which  is  qinte  as  good  as  pure  silver  for  plastic  opera- 
tions, can,  be  obtained  of  Codman  &  Shurtleff.  Boston,  at  about  one-eighth  the  cost  of 
silver. 


M.\ii:/!/\f.s  FOR  si'miES.  .'5;59 

if"  |M<»tr(tcil  1)\-  :i>(|>ti<-  (lr('»iiiu: wliitli    in  jxyiHH-olfjfrical  wr)rk   is  not 

alwiiNs  |)(t.-«sil)lf — tlicy  may  I'cmain  rican  I'or  a  \v<'<'In,  hnt  afb-r  that,  in 
(•((nst'iincnco  ni'  tlicir  al)soi-l>in^'  t|iiMliti(s,  tlicy  arc  lialdc  to  Ix-i-onjc 
soptif  tuul  to  cause  suppuration.  Sutures  and  li<ratures  »jf  silk  in  the 
aluloininal  cavitv,  however,  do  not  heconic  se|)tic  or  pnKhice  suj>pu- 
ration  it"  thi'  oj)cration  has  been  aseptii-,  and  they  may  therefore  he 
left   permanently,  heinir  more  rcliahle  than  eatjrnt. 

Caff/ut,  if  aseptic  when  ustnl,  is  less  liable  to  produce  suppuration 
than  silk  ;  it  usually  disappears  by  absorption  in  four  or  five  days — 
makes  an  excellent  lij^ature  for  small  vessels  in  plastic  operations,  in 
which  it  mav  be  cut  short  and  the  wound  closed  over  it.  Catgut  sutures 
are  useful  also  for  operations  on  the  vaginal  wall  or  cervix  when  per- 
formed in  connection  with  perineorrhaphy,  because  they  disapix-ar  in  a 
week  l)v  absorption,  and  thereby  obviate  the  necessity  of  distending  the 
recently-unite<l  perineum  for  tiieir  removal.  But  the  al)sorbability  of 
catgut  may  cause  it  to  disappear  too  soon,  and  the  wound  then,  deprivetl 
of  needed  support,  may  reopen.  To  guard  against  this,  Lister  advises 
that  it  be  soaked  tor  thirty-six  hours  in  a  mixture  of  chromic  acid  1 
part,  carbolic  acid  200  parts,  and  water  4000  parts,  and  then  dried. 
Just  before  using  it  should  be  moistened  with  carbolic-acid  Mater.  M. 
D.  Mann  of  Buti'alo,  after  considerable  experience,  says  that  catgut  pre- 
pared in  this  way  gives  little  or  no  trouble  from  too  rapid  absorption. 

The  silver  suture,  with  which  Marion  Sims  demonstrated  the  curabil- 
ity of  vesieo-vaginal  fistula,  is  most  frequently  employed  for  gyneco- 
logical plastic  operations  in  the  United  States.  It  is  specially  adapted 
for  plastic  surgery,  because  it  cannot  by  the  absoq:)tion  of  moisture 
become  septic  and  produce  inflammation  and  suppuration,  with  conse- 
quent s.welling  and  strangulation  of  the  included  tissues.  It  is  indeed 
not  likely  to  cut  through  or  to  cause  strangulation,  even  though  left  in 
place  for  a  month.  Xo.  26  silver  wire  is  generally  recommended  for 
perineorrhaphy,  Xo.  27  for  trachelorrhaphy,  and  Xo.  28  for  vesico- 
vaginal fistida  ;  but  the  heavy  Xo.  26  Avire  is  less  liable  to  cut,  gives 
better  support  to  the  wcjund,  and  is  generally  suitable  for  all  plastic 
gynecological  operations. 

Comparatively  speaking,  aseptic  silk  or  catgut  sutures  may  l)e  use<l 
for  any  jilastic  operation,  and  in  the  hands  of  a  skilful  operator  they 
usually  prove  satisfactory  ;  but  the  former  become  septic  in  a  few  days, 
and  the  latter  may  be  absorbed  too  soon  ;  either  material,  therefore,  is 
less  reliable  than  silver.  Silver  sutures  are  generally  to  be  preferrcnl 
in  plastic  operations,  and  especially  in  operations  which  require  them  to 
be  left  for  more  than  six  or  seven  days,  or  after  which  there  may  be 
traction  on  the  sutures  or  a  tendency  to  gajiing  of  the  wound.  Such 
operations  include  trachelorrhaphy,  vaginal  fistula,  and  the  extravagi- 
nal  portion  of  colpo-perineorrhaphy.     But  in  the  intravaginal  portion 


340    GE^'EEAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

of  colpo-perineorrhaphy  silk  or  catgut  is  preferable  to  silver,  and  catgut 
is  specially  applicable  to  the  vaginal  portion  of  Emmet's  ne^v  operation 
of  perineorrhaphy.  Eor  trachelorrhaphy  silver  sutures  are  preferable 
even  when  the  j)erineum  is  closed  at  the  same  time,  because  in  uterine 
tissue  they  do  not  cause  suppuration  even  if  left  for  three  or  four  weeks, 
when  the  new  perineum  will  be  firm  enough  to  permit  the  careful  pas- 
sage of  the  speculum  for  their  removal. 


Assistants. 

Four  assistants  are  usually  required  for  a  gynecological  operation — 
one  to  give  ether,  one  to  wash  sponges,  one  at  the  operator's  left  to  hold 
the  speculum,  and  one  at  the  operator's  right  to  sponge  and  render 
other  assistance.  If  the  operation  be  on  the  perineum  or  vulva,  and 
the  patient  be  in  the  dorsal  decubitus,  the  thighs  must  be  flexed  and 
held  in  the  lithotomy  position  by  the  two  assistants  on  the  right  and 
left.  The  assistants  in  charge  of  the  ether  and  sponging  should  be 
physicians.  The  washing  of  sponges  and  holding  of  the  speculum  may 
be  done  by  nurses.  The  occasional  occurrence  of  acute  synovitis  in  the 
knee-joint  following  operations  on  the  perineum  was  unexplained  until 
Dr.  E.  H.  Webster  of  Evanston,  Illinois,  suggested  that  while  holding 
the  thigh  in  the  lithotomy  position  an  assistant  by  carelessly  throwing 
his  own  weight  upon  the  patient's  leg  or  by  leaning  heavily  upon  it 
might  flex  the  joint  to  a  dangerous  degree.  Various  contrivances  have 
been  devised  for  holding  the  legs  when  in  this  position,  but  they  are 
unnecessary. 

Miscellaneous  Instruments. 

When  the  field  of  gynecological  diagnosis  and  therapeutics  was 
chiefly  confined  within  the  circumference  of  the  cervix  uteri,  the 
various  cylindrical  bivalve  and  polyvalve  specula  were  seemingly  ade- 
quate to  the  needs  of  the  practitioner ;  but  the  development  of  surgical 
gynecology,  especially  that  relating  to  the  puerperal  lacerations  and 
other  injuries,  dates  from  the  invention  of  the  perineal  retractor  of 
Marion  Sims. 

In  the  United  States,  Drs.  Sims  and  Emmet  with  Sims's  speculum, 
the  latero-prone  or  Sims's  position,  and  the  silver  suture  gave  to  j)las- 
tic  surgical  gynecology  its  greatest  impulse.  Then  Gustav  Simon  and 
his  followers  in  Germany  with  a  modification  of  Sims's  speculum,  the 
dorsal  position,  and  the  silk  suture  popularized  the  operative  method 
now  almost  universally  adopted  throughout  Germany, 

Shns^s  Speculum. — In  order  to  appreciate  the  action  of  Sims's  specu- 
lum it  becomes  necessary  to  study  the  effect  of  the  latero-prone  or 


M/s( •i:l la sf.o [ w  lysrn i 'mi:sts.  :\\\ 

Sirns's  position  upon  tin-  |Klvi<-  oii^nn^.  IJkf  tlic  kiicr-i-lu'st  position, 
of  which  it  is  a  niodilication,  it  causes  the  vaji;iiia  to  fill  with  ail',  ami 
the  anterior  and  postei-ior  vaj::inal  walls — or,  to  speak  more  coiiij)re- 
hcMLsively,  the  piil)ic  an<l  sacral  setrineiits  of  the  pelvic  {{(tor — to  .-ep- 
arate.  The  speciiluni  then  exau-^erates  tin-  etfect  of  this  position  hv 
hookini;-  (tr  drawinj^  back  the  j»ei-inenni,  which  <'Xj)oses  ahno-t  tin? 
entire  surface  of  the  widoly-o|)eiie(l  vairina,  and  causes  the  cervix  to 
he  drawn  somewhat  forward  toward  the  vulva.  Two  recpiirements  are 
essential  to  th(>  successful  use  of  Situs's  sj>eculum — correct  |)osition  of 
the  patient  ami  |»i-oper  lioidiiiii"  of  the  in>trument.  The  patient  is  to  lie 
j)laced  on  the  left  side,  the  hi[»s  l)ein«r  over  the  left-hand  corner  of  that 
end  of  the  table  which  is  t(»ward  the  operator;  the  knees  are  to  Im? 
drawn  up  toward  tlie  abdomen,  anil  the  right  thigh  flexed  slightly  more 
than  the  lefV.  The  left  arm  then  rests  behind  the  patient  on  the  table. 
This  permits  the  right  shoulder  to  be  thnjwn  forward  and  depressed 
toward  the  right  side  of  the  table,  so  that  the  position  becomes  latero- 
jn'one — /.  e.  lateral  and  slightly  prone  at  the  hips,  and  almost  whollv 
})rone  at  the  shoulders.  The  left  side  of  the  head  rests  upon  the  table, 
the  face  looking  to  the  right.  The  right  arm  hangs  over  the  right  side 
of  the  table,  and  the  long  axis  of  the  trunk  extends  obliquely  across  the 
table  from  left  to  right. 

Modifications  of  Sims's  speculum  to  make  it  self-retaining  and  to  dis- 
pense with  the  assistant  have  been  devised  by  Emmet,  Studley,  Hunter, 
Erich,  and  others,  but,  for  surgical  purposes  at  least,  with  but  imper- 
fect success.  Proper  holding  of  the  instrument  and  correct  position 
of  the  patient  will  secure  more  light  and  space  than  can  be  gained  bv 
any  other  means.  A  detailed  description  of  the  manner  of  using 
Sims's  speculum  will  be  found  in  the  article  on  "  Gynecological  Diag- 
nosis." For  surgical  operations  or  explorations  in  the  rec-tum  Sims's 
speculum  and  Sims's  position  are  incomparably  superior  to  all  others. 

Simon's  speculum  (Fig.  139)  is  a  perineal  retractor  similar  to  Sims's, 
but  with  shorter  and  flatter  blades,  which  are  made  of  different  shapes 
and  sizes,  and  are  adjustable  on  a  handle,  so  that  they  may  be  changed 
to  meet  the  requirements  of  the  case.  It  is  the  favorite  instrument  of 
the  Germans,  and  differs  from  Sims's  chiefly  in  the  manner  of  its  use, 
which  requires  the  patient  to  be  in  the  dorsal  decubitus  and  the  thighs 
to  be  flexed  as  in  the  lithotomy  position.  An  objection  to  the  instru- 
ment is  the  greater  liability  of  the  vesico-vaginal  wall  to  fall  down 
tcjward  the  speculum  and  of  the  lateral  walls  to  fall  together,  and 
thereby  to  obscure  the  field  of  operation.  To  obviate  this,  Simon  uses 
a  smaller  though  similar  retractor  which  acts  in  the  opposite  direction, 
like  the  anterior  blade  of  the  bivalve  speculum.  Lateral  depressors 
also  are  often  required  on  either  side,  all  of  which  are  more  or  less  in 
the  operator's  way.     Moreover,  tlie  introduction  of  the  sound,  curette, 


342   GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

or  of  other  instruments  to  the  interior  of  the  uterus  is  more  difficuk  in 
the  dorsal  than  in  Sims's  position,  and  if  the  organ  be  ant  everted  or 
anteflexed  the  instrument  is  especially  liable  to  be  arrested  at  some 
point  on  the  posterior  wall  of  the.  cervix  or  at  the  internal  os,  and 
refuse  to  pass  farther.  Sims's  speculum  is  more  easily  held,  requires 
fewer  assistants,  fewer  attachments  and  depressors,  than  Simon's.  It 
gives  the  maximum  amount  of  light  and  space,  and  therefore  probably 
never  will  l^e  superseded  bv  any  other  instrument. 


Fig.  139. 


Simou's  Specula  :  blades  of  various  sizes  and  shapes. 

Vulsellum  forceps,  similar  in  constniction  to  those  shown  in  Fig. 
154,  but  with  heavier  blades  and  longer  teeth,  are  designed  for  various 
operations  on  and  about  the  cer%dx.  They  are  used  for  holding  the 
cervix  during  amputation  and  for  making  traction  in  the  removal  of  a 
uterine  fibroid.  Emmet's  double  teuaculimi  forceps  (Fig.  140)  answers 
the  same  purpose.  It  is  well  adapted  for  the  removal  of  any  intra- 
uterine mass  requiring  traction ;  its  teeth  lap  one  over  the  other  when 
closed,  which  adds  materially  to  the  strength  of  their  grasp ;  its  blades 
and  handles  are  bent  in  opposite  directions  with  a  .sigmoid  cur^'e,  so 


Mis<  j:ij.a si:<) i :s  i.wsri: i  miixts. 


343 


that   it   may   l>c   out    i>|'  the  (ipi-rator's   \\:iy    when    IhM    hv   :iii    a~-i>t- 
aiit. 

Kimiict's  (l<iiil)l('  tciuiciiliiiii  is   used  lor  >tca<l\iMti-  tlic  iitci'iis  (liiriii<^ 
amputatitiii  oi'tlu'  cervix  or  (Im-in^i-  intia-iitcriiic  ujiciatioii.-.     It  is  licld 

I'lu.  14U. 


Emmet's  Double  Tenaculum  Forceps. 

in  the  Icl't  liaiid,  and  may  he  introduced  into  the  cervical  canal  with  its 
teeth  adjusted,  as  in  Fig'.  141  ;  then  by  depressing  the  thumi>-piece  at 
A  the  hUules  are  widely  separated,  the  canal  put  upon  the  stretch,  and 
its  opposite  walls  penetrated  and  held  by  the  teeth.     Its  hold  upon  the 

Fig.  Ul. 


Emmet's  Double  Tenaculum. 


tissues  may  be  loosened  by  drawing  back  the  ratchet  at  B  with  the 
index  finger, 

Sponge-Holders. — For  intravaginal  operations  three  or  four  or  more 


Fig.  142. 


-iiiis's  Siiongc'-hulder. 


.sponge-holders  (Fig.  142),  twelve  inches  long,  are  usually  required,  in 
which  sponges  trimmed  to  the  desired  size  and  shape  may  be  fa-stened. 
Scissors. — The    minor   gynecological  operations  may  be  performed 
either  with  the  sci.ssors  or  with  the  knife,  and  the  choice  depends  much 


344    GENERAL   CONSIDERATION   OF  GYNECOLOGICAL  SURGERY. 

upon  the  education  and  habits  of  the  operator.  The  scissors  certainly 
cause  less  hemorrhage,  and  when  one  becomes  accustomed  to  their  use 
he  can  work  more  accurately  and  more  rapidly.  Any  strong,  well- 
made,  slightly  curved  scissors  wall  suffice,  but  those  of  Emmet  are 
specially  adapted   to    intravaginal,    perineal,    and    vulvar    operations. 

Fig.  143. 


Emmet's  Scissors  for  dividing  the  Cervix. 


Fig.  143  show^s  a  pair  of  blunt-pointed  scissors,  with  straight  blades 
bent  laterally  upon  the  shank  at  an  angle  of  forty-five  degrees.  They 
are  useful  for  dividing  the  cervix,  for  making  an  artificial  vesico-vaginal 
or  urethro-vaginal  fistula,  and  for  dividing  cicatricial  bands  in  the  vagina. 
The  slightly-  and  strongly-curved  scissors  are  almost  indispensable 

Fig.  144. 


Emmet's  Slightly-curved  Scissors. 

for  denuding  in  plastic  operations ;  the  slightly-curved  (Fig.  144)  are 
used  for  perineal  and  for  ordinary  intravaginal  denudation ;  the  strongly- 


FiG.  145. 


Emmet's  Strongly-curved  Scissors. 

curved  (Fig.  145)  are  convenient  for  denuding  a  strip  high  up  across 
the  vagina  or  cervix  uteri  in  fistula  and  cervix  operations.     The  scis- 


MISCELLANEO  US  INSTR  UMENTS. 


345 


sors  rcprc'sontcd  in  V\\j:^.  1  II  ami  1  15  arc  curved  toward  tlic  rinlit,  and 
arc  intended  to  he  used  in  tlic  iMi^lit  liand.  lOinniet  mentions  al>o  two 
others  with  curves  to  the  left,  hut  it  is  scarcely  j>ossihlc  to  iinajiine  an 
operation    in    which   the   lattei'   would    he   neccssarv. 

Kniniet's  wire  scissors,  with  hlades  |)ointed  and  sli<xlitlv  curve<l  on 
the  Hat,  are  iisctul  lor  cuttinii'  wire,  and  s<»nietinies  lor  cutting  out  cica- 
tricial tissue,  'i^he  sli<ihtly-curved  scissors  ol"  Fig.  144  answer  all  the 
purposes  for  which  straight  scissors  are  usually  cniplove(l. 

Eniniot's  hall-and-socket  knife  (Fig.  14(1)  has  a  hhule  which  niav  ho 
firmly  attached  at  any  angle  to  the  shank  hy  closing  the  handles,  which 

Fig.  146. 


Emmet's  Ball-and-Socket  Knife. 

are  provided  with  a  lock  at  the  end.     The  knife  may  be  used  in  places 
whicli  are  inaccessible  to  the  scissors. 

The  Tenaculum. — Xuinerous  tissue-forceps  have  been  devised  for 
grasping  the  tissues  to  be  denuded  or  excised,  but  a  properlv-constructefl 
tenaculum  in  the  educated  hand  is  the  most  convenient  and  effective 
instrument  for  this  purpose.     Witli  the  tenaculum  the  operator  can 

Fig.  147. 


Uterine  Tenaculum. 


pick  up  and  hold  a  smaller  amount  of  ti.-^sue,  and  can  therefore  denude 
more  su]K-rficially,  than  is  possible  with  the  tis.sue-forceps.  The  instru- 
ment (Fig.  147)  has  a  perfectly  straight  hook  a  little  more  than  a  quar- 
ter of  an  inch  long  and  at  right  angles  to  the  shaft.  It  .should  be  .so 
strong  and  .stiff  that  considerable  force  may  be  applied  in  the  line  of 
the  in.strument  without  breaking  or  bending  the  hook,  or  in  a  lateral 
direction  without  liending  the  shaft.  The  uterine  tenaculum  is  u.<eful 
not  only  in  denudation,  but  also  in  almo.st  ever^-  .step  of  a  gvnecoloirical 
examination  or  operation.  In  some  operations  as  many  as  four  of  them 
may  be  required. 


346   GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

Plastic  Operations. 

The  subject  comprehends  all  oj)erations  for  the  repair  of  the  puerperal 
lacerations  and  injuries,  such  as  laceration  of  the  cervix  uteri  and  peri- 
neum and  vesico-vaginal  fistula.  Union  by  first  intention,  which  is  an 
essential  requirement  of  plastic  surgery,  Avill  almost  invariably  result 
from  a  correct  operation.  In  certain  cases  of  vaginal  fistula  in  which 
there  has  been  great  loss  of  tissue  from  sloughing,  failures  may  arise 
from  the  cicatricial  character  of  the  parts  or  from  difficulty  in  holding 
the  edges  together.  Perineorrhaphy  in  very  fat  subjects,  especially  when 
the  rupture  extends  through  the  sphincter  ani  muscle,  may  fail  after 
the  most  skilful  operation,  but  generally  the  conditions  of  success  are 
within  the  control  of  the  operator.  These  conditions  are  simple  but 
absolute,  and  the  operator  ^vho  has  neglected  them  cannot  fairly  attribute 
his  failure  to  the  debilitated  state  of  the  patient  or  to  chance  or  to  acci- 
dent. Indeed,  union  must  almost  invariably  follow  if  the  surfaces  to 
be  united  are  properly  prepared  and  kept  in  contact  for  a  week.  The 
first  condition,  antisepsis,  has  been  discussed.  The  others  Mall  be  pre- 
sented in  the  following  paragraphs. 

Denudation. — The  patient  having  been  etherized,  placed  in  posi- 
tion, and  the  field  of  operation  exposed,  the  surfaces  to  be  united 
should  be  denuded.     Correct  denudation  is  a  prerequisite  to  healing 

Fig.  148. 


Denudation  with  the  Tenaculum  and  Scissors. 


by  first  intention.  Surfaces  to  be  united  should  be  so  denuded  that 
when  brought  together  they  will  fit  accurately,  otherwise  a  part  of  the 
denuded  surface,  being  in  contact  with  an  unclenuded  surface,  must  heal 
by  granulation  and  suppuration,  which  ma}^  excessively  irritate  the  rest 
of  the  wound,  and  would  always  produce  cicatricial  tissue,  which  is  very 


PLASTK '  OPERA  TIOSS. 


.347 


Yia.  149. 
A 


(•Kjcctioiiahlc.  riif  tltiiiidcHl  siirfiicc  .-lioiild  Im- .«.iii(i(»tli  and  l"nc  rnini 
sIihmIs,  which  iiiiuht  die  and  1k'<'oiiic  sniirc<'s  (»l"  s('|»(i<-  iidi-ctiuii.  Kvcrv 
particle  of  in(>iid)raiic  oi-  -kin  within  the  area  <>t'  dcniidatioii  .shonld  l>c 
.scrnjnil(iii.>ly  removal.  If  the  surface  l»c  |Mrfceily  healthy,  the  more 
siiperlicial  tlie  (K-niidatioii  the  better,  hut  diseased  and  ci<'atricial  ti.-sues 
do  not  readily  unite,  and  sliould  therefore,  wlien  practicahh-,  he  reinove<I. 
r  Fiw;.  148  sliows  the  action  of  the  tenaeuhun  and  scissor.-  in  denudiu}^. 
The  superiority  of  the  tenaculum  as  a  substitute  for  the  tissne-force]>s 
nmst  l)e<'ome  a|)parent  to  any  one  who  will  familiarize  himself  with  its 
use. 

Xccil/rs. — A  round  nefnlle  is  j)referal)le  to  one  with  a  cuttin}^  e<l<re. 
The  latter  makes  an  incisiMl  wound  which  is  <i;enerally  Uh)  large  for  the 
sutin-e,  hlecnls  more  freely,  is  ])rone  to  suj)purate,  and  requires  more 
time  for  healinu".  The  former  makes  a  j>unctured  woiuid  which  read- 
ily shrinks  down  upon  the  suture,  is  less  liable  to  blee<l  or  to  suj»pu- 
rate,  and  heals  more  (luickly  after  the  removal  of  the  suture.  Many 
of  the  most  dexterous  operators  are  ])artial  to  the  straight  nee<lle  in 
preference  to  the  curved,  espcvially  when  the  long  needle  is  used  as  in 
perineorrhaphy.  The  straight  needle  has  two  advantages :  first,  how- 
ever deej>ly  it  may  be  buried  in 
the  tissues,  the  position  of  its 
jxjint  can  always  be  determined 
from  its  direction  and  length ; 
second,  the  force  em})loyed  in  its 
introduction  being  in  the  direc- 
tion of  the  needle,  it  may  with- 
out danger  of  breaking  be  of 
mucli  smaller  calibre  than  the 
curved  needle,  Avhieh  must  be 
introduced  by  a  force  exerted  in 
the  line  of  a  tangent  to  the  curve. 

The  straight  needle  therefore 
requires  less  force  for  its  intro- 
duction, is  less  liable  to  break, 
and  makes  a  smaller  wound.  Moreover,  the  simple  rotation  of  the 
needle  forceps  on  its  long  axis  by  a  turn  of  the  Avrist  enables  the  (jj)e- 
rator  to  swxx>p  the  straight  needle  around  a  curve  in  the  vertical  plane, 
or  it  may  be  carried  around  a  curve  in  the  horizontal  plane  l)y  loosen- 
ing and  tightening  the  forceps  grasp  upon  the  needle  at  very  short 
intervals,  so  that  the  angle  between  the  forceps  and  the  needle  may 
change  almost  constantly  during  its  passage.  In  this  way  the  straight 
needle  may  be  made  to  carry  a  suture  around  a  curv'e  quite  as  accu- 
rately as  the  curved  needle,  and  ofteji  more  easily.  Obviously,  the 
lock  forceps,  which  do  not  |>ermit  this  freedom  ui'  motion,  are  imsuitetl 


===^ 


A,  .straight  needle  for  external  .«utures  in  peri- 
neorrhaphy. B,  straight  and  curved  needles 
for  operations  on  the  vaginal  walls  and  the 
cervix,  and  for  vesico-vaginal  fistula :  the 
upper  needle  under  B  is  trocar-pointed  for 
very  dense  tissue.  C.  Simpn'.s  strongly -curved 
needles  for  vesico-vaginal  fistula. 


348    GE2sERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

to  such  manipulations.  Fig.  150  represents  Emmet's  needle-forceps 
without  lock.  The  eye  of  the  needle  if  included  in  the  grasp  of  the 
forceps  may  be  crushed ;  to  avoid  this,  grasp  it  on  the  proximal  side 


Fig.  150. 


Emmet's  Needle-Forceps. 


The  spring  between  the  handles  causes  them  to  open  when  the 
grasp  is  relaxed. 


of  the  eye.  The  plain  round  point,  however  sharp,  sometimes  encoun- 
ters great  resistance  in  being  passed  through  dense  tissue.  The  trocar 
point  represented  in  Fig.  149,  B,  or  the  saddler's  point,  is  less  objec- 
tionable than  the  cutting  edge,  and  may  be  introduced  almost  a.s- 
easily. 

Various  needles  with  handles  attached  or  detached  and  of  different 
curves  and  shapes  have  been  devised,  some  Avith  eyes  at  their  points, 
some  without  eyes,  and  others  of  cylindrical  form,  through  which  the 
wire  is  passed  lengthwise  from  one  end  to  the  other.  They  complicate 
rather  than  simplify  an  operation ;  they  make  punctured  or  incised 
wounds  many  times  larger  than  the  sutures  which  they  are  to  contain  ; 
they  are  in  no  respect  suj^erior  to  the  simple  needle  and  thread. 

The  Application  of  Silver  Sutures. — Xo.  26  silver  wire,  the  proper 
size  for  gynecological  oj)erations,  is  too  heavy  to  be  threaded  directly 
into  the  needle,  but  it  may  be  easily  drawn  through  upon  a  loop  of 
silk,  cotton,  or  linen  thread  secured  to  the  eye  of  the  needle  by  a  half 

Fig.  151. 


The  Thread  Loop,  ten  inches  long,  secured  to  the  needle  by  a  half  knot  for  drawing  through 

silver  wire. 


knot,  as  represented  in  Fig.  151.  The  knot  should  be  drawn  tight  to 
prevent  slipping,  and  the  wire  bent  sharply  over  the  loop,  as  shown  in 
Fig.  152. 


PLASTIC  ni'KiiATinss. 


r>.4n 


Vu..  152. 


BefoH'  the  iiitn»(lnctir»ii  oftlic  sntiiics,  approximate  the  (Ifmuhnl  siir- 
facos  with  teiiaciila  t<»  (Ictcnniiic  wlu'tlicr  tluv  arc  of  such  size  and  shajH- 
that  their  union  will  pHnhice  the  (UtiirHl 
result,  and  whetiier  accurate  coaj)tation  of 
their  inar»:ins  can  he  secured  without  un- 
due traction,  which  mijrht  cause  the  sutures 
to  cut  out.  Then  hook  up  the  niar<::iu  of 
the  wound  with  a  tcnacuhun,  introduce  the 
needle,  and  when  its  point  aj)})ears  j)lacc 
the  tenaculum  under  the  point  of  the  nee- 
dle and  apply  counter-pressure,  as  in  Fig. 
152,  until  the  needle  can  ha  seized  and 
drawn  through  with  the  forceps.  Some 
operators  use  the  blunt  hook  (Fig.  153) 
for  counter-pressure,  but  a  strong  tenacu- 
lum which  will  neither  break  nor  bend  is 
often  preferable,  because  it  may  also  be 
fixed  in  the  tissues  at  the  very  point  where 

the    operator    desires    to    force    the    needle    showing  counter-pressure  and  the 
,,,.,,  ^  attached    wire,    nine    to    twelve 

through,    and    it   thereby   ensures   greater     inches  long,  which  is  about  to 
precision   in   directing    the    neetUe   to   its     ^  '^^^"'^  through  by  the  thread 

^    .  .  ®  loop. 

point  of  exit.     The  ase  of  the  tenaculum 
also  avoids  multiplicity  of  instruments. 

Uterine  tissue  is  often  so  dense  that  great  force  is  required  to  drive 


Fig.  153. 


SI-'EP-SBiijaDUDLEY 


Emmet's  Counter-pressure  Hook,  for  making  pressure  beyond  the  point  of  the  needle  as  it  is 
passing  through  the  tissues. 

the  needle  through  it.     For  this  reason  the  passing  of  the  needle  is 
often  the  most  trying  part  of  trachelorrhaphy. 


Fig.  154. 


Vulsellum  Forceps,  with  fine  short  teeth  to  gra.^p  the  cervix  in  passing  the  needle  for  trache 
lorrhaphy.  Between  the  two  teeth  of  each  blade  is  a  deep  opening  to  accommodate  the 
|.a.ssage  of  the  needle.  The  instrument  is  provided  with  scissor-handles,  and  is  about  ten 
inches  long  (modified  from  Hanks). 

In  making  counter-pressure  the  tenaculum  may  slip  and  the  uterus 
receive  a  violent  and  sudden  jerk,  which  is  not  without  danger,  espe- 


350    GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

cially  when  often  repeated.  This  may  be  avoided  and  the  operation 
facilitated  by  holding  the  flap  in  the  vulsellum  forceps  (Fig.  154)  while 
the  needle  is  being  forced  through  between  its  teeth.  These  forceps 
may  be  made  by  filing  the  teeth  of  Hanks's  forceps  shorter  and  finer, 
and  by  filing  a  deeper  opening  between  the  two  teeth  of  each  blade. 
The  sutures  should  be  about  one-fourth  of  an  inch  apart — should 
include  considerable  tissue,  and  if  possible  to  avoid  it  should  not  pass 
through  the  denuded  surface  or  be  in  contact  with  any  portion  of  the 
wound,  because  when  at  a  distance  from  the  denuded  surface  they  are 
less  liable  to  irritate  and  produce  swelling  or  inflammation,  and  are 
therefore  less  liable  to  cut. 

As  each  wire  is  drawn  through  on  the  thread  and  temporarily  secured 
by  a  slipknot,  as  shown  in  Fig.  155,  it  is  held  out  of  the  way  by  an 
assistant  until  all  have  been  passed.     Theii,  one  after  another,  they  are 


Fig.  155. 


Fig.  156. 


Before  twisting,  showing  a  su- 
ture in  position,  with  the  slip- 
knot. 


Before  twisting,  all  the  sutures  in  position.  One 
is  being  separated  from  the  others  by  a  tenac- 
ulum preparatory  to  twisting. 


picked  up,  as  in  Fig.  156,  and  the  traction  is  made  upon  the  free  end 
until  the  slipknot  has  been  drawn  down  upon  the  tenaculum  Avithin  an 
inch  of  the  wound.    (See  Fig.  157.) 

To  prevent  the  ends  of  the  suture  from  slipping  out  of  the  grasp  of 
the  twisting  forceps,  the  wire  is  twisted  for  a  short  distance  below  the 
slipknot  by  rotating  the  handle  of  the  tenaculum  two  or  three  times 
between  the  thumb  and  finger  (Fig.  158).  The  twisting  forceps  are 
now  applied  over  the  slipknot,  the  loose  wire  cut  off,  and  the  suture 
shouldered  by  the  tenaculum  (Fig.  159). 

When  the  twisting  forceps  have  been  applied  and  the  suture  has  been 
shouldered  (Fig.  159),  the  No.  26  wire  will  be  found  stiff  enough  to 
hold  the  margins  of  the  wound  in  contact.     The  shield  (Fig.  161)  is 


PLASTIC  orr.i:.  i  wo a'.v. 


{51 


now  :i|)|)lic<l,  ami  the  siitiirt'   is  t\vi>tc<l  duwii  to  the  sliouldci-  {V'xv:.-  1 'i*-^)) 
hut    no    rarllicr,    Ix'caiisc.  tlic   iiiar«;'ins  ol'  tlic   wdiiiid    licin^-  ali'cady    in 


Fig.  1A7. 


Y\u.  l.'.s. 


The  slipknot  being  drawn  down 
on  a  tenaculum. 


Twisting  a  suture  with  the  tenaculum  to  pre- 
vent the  wire  from  slipping  out  of  the  grasp 
of  the  twisting  forceps. 


contact,  the  wire  if  twisted  beyond  the  .shoulder  woidd  ."^trano-ulate  the 
tissues,  and  either  cut  through  them  or  cause  sloughing.     If  the  wound 

Fig.  159. 


Shouldering  a  Suture. 


cannot   he  brought  together   or  nearly  t(_)gether  by  shouldering,  it  is 
evident  that  the  traction  upon  the  sutures,  even  though  they  be  twisted 


352    GENERAL   CONSIDERATION   OF  GYNECOLOGICAL  SURGERY. 

only  to  the  shoulder,  may  cavise  them  to  cut  or  the  flaps  to  slough,  and 
the  operation  to  fail.  The  object  of  shouldering,  therefore,  is  twofold  : 
first,  to  show  that  the  flaps  can  be  held  together  without  undue  traction ; 
second,  to  limit  the  twisting  and  thereby  prevent  strangulation.  The 
twisted  portion  of  the  suture  should  now  be  bent  down  upon  the  sur- 

FiG.  160. 


Emmet's  Modittcation  of  iSiius's  Twisting  Forceps. 

Fig.  161. 


Sims's  Shield. 


face  in  the  direction  where  it  will  cause  the  least  irritation,  and  cut  off 
about  half  an  inch  from  the  line  of  union.    (See  Fig.  163.) 

Before  twisting  the  sutures  all  bleeding  points  should  be  controlled 
by  torsion  or  by  fine  catgut  or  fine  silk  ligatures,  cut  short.  Catgut 
makes  the  best  ligature  for  small  vessels  in  the  deeper  portions  of  the 
wound,  because  of  its  ready  absorbability. 

Thorough  sponging  or  irrigation  for  the  purpose  of  cleansing  the 


Fig.  162. 


Fig.  163. 


Twisting  a  Suture. 


Bending  the  twisted  portion  of  the  suture 
down  upon  the  vaginal  surface. 


wound  during  the  twisting  of  the  sutures  is  imperative.  Any  particle 
of  coagulum  or  shred  of  tissue  left  in  the  wound  will  act  as  a  foreign 
body,  will  decompose,  and  may  prevent  union.  Just  before  twisting, 
two  of  the  sponges  on  the  sponge-holders  may  be  trimmed  to  a  small 


PLASTIC  (>ri:i: ATioss. 


353 


sI/<' ami  III  a  foiiiral  slia|t('  with  tln'  scissors,  Utr  use  wliilc  the  woiiikI 
is  Ix'iiiLi"  closcil.  'Pin-  ))rac(ic('  of  opcraliiiji;  under"  tlic  coiistaiit  hot 
antiseptic  (loiiclie  enables  {\\v  operator  to  discard  the  spctiij^e  entirely 
and    to  secure   perlect    cicaidiiicss.     (See  Antisepsis.) 

The  application  ot"  the  silver  sntiire  to  the  vajiina  and  cervix  differs 
in  some  details  from  its  ap|»Iication  in  perineorrhaphy,  but  ll^r  the 
technique  of  special  ojx'rations  the  student  is  referred  to  the  special 
suhjects. 

The  aj'lcr-/rc(ifiii(iif  has  been  j)artially  discussed  under  Antisepsis  and 
otliei-  means  to  jireN'cnt  pelvic  inflammation.  Further  information  may 
be  found  in  those  articles  which  relate  to  special  oj)erations. 

licmond  of  iSati(rc{i. — Sutures  alxjut  the  vulva  and  perineum  slnndd 
be  removed  in  about  seven  days.     If  left  much  longer  they  become 


Removing  a  gilver  Suture. 

loose  or  cause  suppuration.  In  the  vaginal  walls  they  may  be  left,  if 
necessary,  several  days  lonjrer.  In  the  cervix,  where  suppuration  seldom 
occurs,  they  should  be  removed  in  ten  to  fourteen  days,  unless  perineor- 
rhaphy has  been  done  at  the  same  time,  in  which  case  their  removal 
cannot  safely  be  undertaken  in  less  than  three  or  four  weeks.  To 
remove  a  suture  seize  the  twisted  portion  of  the  wire  Avith  a  dressing- 
forceps,  and  with  the  wire  scissors  cut  the  nearest  side  of  the  loop. 
(See  Fig.  1G4.)     This  tends  to  hold  the  freshly-united  Avound  together 

Voi,.  I.— 23 


354    GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

during  the  withdrawal  of  the  wire.     If  the  loop  be  cut  on  the  farther 
side,  its  removal  would  tend  to  reopen  the  wound. 


Dilatation  of  the  Uterus. 

It  is  impossible  by  means  of  any  speculum  yet  devised  to  inspect  the 
interior  of  the  uterus,  but  its  cavity  may  be  made  surgically  accessible 
to  the  palpating  fingers  and  to  various  instruments  by  dilatation.  The 
principal  objects  of  dilatation  are  to  overcome  stenosis  or  stricture  of 
the  uterine  canal,  to  diagnose  and  remove  causes  of  pathological  uterine 
hemorrhage,  such  as  granulations,  polypi,  and  the  remains  of  abortion, 
and  to  cure  pathological  flexions.  The  uterus  may  be  dilated  by  incis- 
ion, by  tents,  by  graduated  sounds,  and  by  dilators  with  diverging  blades 
constructed  on  the  principle  of  the  glove-stretcher. 

Incision  of  any  portion  of  the  uterine  canal  may  be  required  to 
render  the  endometrium  accessible  for  instrumental  or  manual  inter- 
ference. But  incision  is  specially  applicable  to  the  lower  part  of  the 
cervical  canal  and  to  the  external  os,  and  is  performed  for  congenital 
or  acquired  stenosis  to  ensure  the  free  outflow  not  only  of  menstrual 
fluid,  but  also  of  the  uterine  mucus,  which  if  retained  becomes  offen- 
sive, irritates  the  intra-uterine  mucosa,  and  causes  hypersecretion. 
Oftentimes  the  uterine  secretions  are  so  impeded  in  their  passage 
through  the  strictured  os  externum  that  they  accumulate,  distend  the 
uterine  cavity,  and  ai'e  thrown  off"  at  irregular  intervals  with  expulsive 
pains  simulating  labor-pains.  This  explains  certain  cases  in  which 
there  is  a  recurrence  in  the  intermenstrual  period  of  all  the  painful 
phenomena  of  obstructive  dysmenorrhoea.  In  such  cases  permanent 
cure  succeeds  the  operation  recommended  by  Fritsch '  of  Breslau,  which 
is  as  follows  :  The  patient  being  in  Sims's  lateral  position,  the  vaginal 
portion  is  seized  from  the  inner  side  of  the  os  with  a  sharp  tenaculum. 
An  incision  is  then  made  one  centimeter  long  in  the  direction  opposite- 
to  the  traction  of  the  tenaculum ;  this  is  repeated  on  the  opposite  side 
and  in  front  and  behind.  The  four  flaps  thus  formed  are  seized  one 
after  another  with  a  tenaculum,  and  about  half  of  each  cut  away. 
After  this,  retraction  of  the  remaining  portion  of  the  flaps  occurs  and 
the  external  os  remains  funnel-shaped.  The  ordinary  bilateral  incisions 
show  a  decided  tendency  to  reunite,  and  are  therefore  objectionable.  The 
incisions  may  be  made  with  the  scissors  (see  Fig.  143)  or  with  the  knife 
(see  Fig.  146). 

Schroeder  of  Berlin^  in    certain    cases,  especially  of   intra-uterine 

polypi,  incises  the  cervix  bilaterally,  seizes  the  posterior  lip  with  a 

vulsellum   forceps,  and  with  his  finger  as   a  dilator  works  his  way; 

to  the  uterine  cavity.     The  uterus  dilated  in  this  way  and  Avell  drawn. 

^  Diseases  of  Women,  Am.  ed.  ^  American  Journal  of  Obstetrics. 


DiLATATiDX  OF  Till:  rTi'.in's.  :*,rtr) 

(lowM    is  very  accc.-.-ililc.      In   Sclii'ncilcr's  iiiciIkkI    the   lalcral    incisions 

I'xtcntl  into  tlir  (laiiu't'i'i'iis  nci^lilturli I  of  (he  |>araiMcti-ia.     Tlic  >al(.'ty 

of  tlic  operation  nnist  tlicrcrorc  (Icpcnd  npon  tlioronjili  antisepsis.  It 
is  inipraetieable  in  u  ri«>id  uterus  to  incise  and  dilate  accordin^r  to 
Sdiroeder's   method. 

Tents. — Spon;^-e,  sea-tan<ile,  and  tu[)elo  are  the  materials  eomnmidy 
used.  If  intrcnhieed  into  tht-  uterus  in  the  dry  compressed  state,  the 
nnicoiis  seeretion,  stiinuhited  by  their  proscnoo,  causes  them  to  swell 
laterally  to  a  diameter  two  or  tlirce  times  greater,  and  correspondingly 
to  dilate  the  canal. 

Sponge  tents,  which  have  a  dilating  power  of  about  three  times  their 
diameter,  are  made  t>f  disinfected  compressed  sponge,  straight  or  curved 
to  tit  the  uterine  canal,  and  perforated  from  end  to  end  to  admit  a  strong 

Fig.  165. 


A  Sponge  Tent  with  thread  passing  through  it.    Before  introduction  the  ends  of  the  thread 
should  be  tied  together.i 

thread  (see  Fig.  165),  by  means  of  wliieh  the  tent  may  be  held  together 
during  removal.  Otherwise  a  fragment  may  be  left  behind  and  be  an 
unsuspected  source  of  dangerous  infection. 

The  sponge  tent  not  only  expands,  but  at  the  same  time  softens  the 
walls  of  the  uterus,  and  thereby  prepares  them  for  further  dilatation 
and  renders  the  cavity  more  accessible  for  surgical  manipulation  ;  in 
this  respect  it  is  more  effective  than  tupelo  or  laminaria,  and  much  more 
effective  than  steel  dilators,  M-hich  usually  leave  the  uterus  so  elastic  that 
immediately  after  their  removal  the  introduction  of  the  finger  or  of  an 
instrument  for  diagnostic  or  surgical  purposes  may  be  impossible 
without  further  dilatation.  But  the  softening  effect  is  the  result  of 
excessive  irritation,  congestion,  and  secretion  due  to  the  presence  of 
the  sponge.  Under  such  conditions  it  may,  in  an  incredibly  short 
time,  become  offensive  and  dangerously  septic  from  decomposition  of 
the  absorbed  secretions.  It  often  also  becomes  so  adherent  and  incor- 
porated with  the  intra-uterine  membrane  that  portions  of  the  epithelial 
layer  may  be  stripped  off  with  its  removal.  The  surfaces  thus  exposed 
would  furnish  a  ready  avenue  for  the  absorption  of  the  secretions.     Dis- 

'  Tkoma.^  on  the  Diseases  of  Women,  p.  lOo,  Oth  etl. 


356    GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

astroiis  results  seldom  follow  the  application  of  a  single  sponge  tent 
unless  the  patient  has  suliered  from  a  previous  cellulitis  or  peritonitis, 
but  the  danger  increases  rapidly  with  the  introduction  of  the  second 
and  third.     Many  operators  now  discard  them  altogether. 

Tupelo  tents,  made  from  the  tupelo  tree  [Ni/ssa  aquatica),  expand 
less  powerfully  but  more  rapidly  than  sponge  to  about  double  their 
compressed  size,  and,  inasmuch  as  they  do  not  so  readily  become  offen- 
sive from  decomposition  of  the  absorbed  secretions,  they  are  less  dan- 
gerous. They  are  straigLt  and  inflexible,  and  therefore  not  easily  intro- 
duced in  cases  of  acute  flexion,  especially  when  there  is  immobility  at 
the  angle  of  flexure.  They  are,  however,  very  smooth,  and  slip  into 
place  when  the  canal  is  straight  or  nearly  straight  more  easily  than 
sponge.  If  the  tent  selected  is  found  on  trial  to  be  too  large,  it  need 
not  be  thrown  away,  but  may  be  easily  cut  down  to  the  required  size 
with  the  penknife.  A  standard  author  has  included  among  the  many 
advantages  of  the  tupelo  tent  the  possibility  of  recompressing  it  for 
rej)eated  use,  but  for  obvious  reasons  such  a  practice  can  be  neither  safe 
nor  permissible. 

Laininaria  tents,  also  called  sea-tangle  tents,  have  more  expanding 
power  than  tupelo  and  less  than  sponge,  but  their  action  is  so  slow  that 

they  are  liable  to  be   expelled 
^'''"      ^'  from  the  uterus  before  they  have 

become  sufficiently  extended  to 
be  self-retaining.  They  have 
but  one  advantage  over  tupelo, 
which  is  their  flexibility.  After 
soaking  in  warm  water  for  a  few 
minutes  they  may  be  bent  to 
any  desired  curve,  and  may  therefore  be  introduced  in  cases  of  uterine 
flexure.  Fig.  166  represents  a  laminaria  tent  perforated  from  end  to 
end  to  make  it  dilate  more  rapidly,  according  to  the  recommendation 
of  Dr.  Greenhalgh  of  London.  Expansion  of  laminaria  is  very  slow, 
requiring  thirty-six  hours  for  the  maximum  dilatation. 

Introduction  and  Removal  of  Tents. — Unless  the  uterus  be 
so  low  that  the  os  externum  is  near  to  the  \mlva,  a  speculum  will  be 
required  for  the  introduction  of  a  tent.  Sims's  speculum  is  most  suit- 
able, and  indeed  indispensable  in  difficult  cases,  especially  when  the 
uterus  is  much  anteflexed  or  anteverted.  Before  introducing  the  tent 
the  vagina  and  \'Tilva  should  be  thoroughly  cleansed,  the  cervix  exposed 
by  the  speculum,  and  the  direction  and  curve  of  the  uterine  canal  ascer- 
tained by  the  probe ;  then  a  tent  of  corresponding  curve  should  be 
seized  in  the  forceps  and  introduced  while  the  cervix  is  fixed  with  a 
tenaculum,  as  shovm  in  Fig.  167.  A  small  tampon  of  antiseptic  cot- 
ton should  then  be  placed  against  the  cervix  to  hold  the  tent  in  place. 


A  Sea-tangle  Tent. 


DILATATIOS   or   Till-:    CTl^RUS. 


357 


Tlif  time  ivtiuiroil  for  a  s|)()nn;c  or  iiijicId  t<»  ivacli  its  luaxiimitii dilata- 
tiuii  is  tVoiu  six  to  twelve  lioiirs.  Several  small  tents  may  l)e  iiitro- 
diieetl  at  one  time  instead  <it"  a  single  largo  one. 

The  tent   may  sometimes  he   removed  by  traetion  <tn  the   attached 
thread,  but  when  considerable  force  is  re([uired  it  is  better  to  use  tlie 

Fio.  107. 


Introduction  of  a  Tent  (Sims's). 


speculum  and  forceps,  and  in  making  traction  to  use  counter-pressure 
against  the  cervix,  which  may  be  steadied  by  placing  tsvo  fingers 
against  it,  or  by  fixing  it  with  the  vulsellum  forceps,  or  by  encircling 
it  with  the  fenestrated  end  of  a  Sims's  depressor.  After  the  removal 
of  the  tent  some  blood  usually  flows  from  the  intra-uterine  surface, 
which  is  usually  more  or  less  abraded,  especially  if  a  sponge  tent  has 
been  used,  and  the  endometrium  should  therefore  be  thoroughly  washed 
out  with  an  antiseptic  solution,  to  be  followed  with  an  application  of 
Churchill's  tincture  of  iodine  over  the  entire  uterine  cavity.  In  cases 
ref[uiring  further  dilatation  the  iodine  should  be  omitted  until  the  last 
tent  has  been  removed.  The  danger  of  continuous  dilatation  by  intro 
ducing  one  tent  after  another  is  very  great.  As  already  stated,  the 
alarming  results  have  generally  followed  the  use  of  the  second  or  the 
third  tent,  seldom  the  first.  A  tent  should  not  be  allowed  to  remain 
in  the  uterus  more  than  twenty-four  hours  under  any  circumstances, 
and  generally  not  more  than  twelve. 

Graduated  Sounds. — The  uterus,  like  the  urethra,  may  be  dilated 
by  means  of  graduated  sounds.  Fig.  168  shows  Fritsch's  uterine  dila- 
tors. Peaslee,  Hegar,  and  Hanks  have  devised  similar  instruments 
which  are  equally  serviceable.  They  are  particularly  adaptetl  to  cases 
in  which  the  abdominal  walls  are  thin  and  lax,  so  that  the  uterus  may 
be  easily  fixed  by  the  hand  oxqy  the  abdomen,  while  one  sound  after 


358    GENERAL   C.ONSIDEBATION  OF  GYNECOLOGICAL  SURGERY. 

another  is  forced  into  the  canal  until  the  required  dilatation  is  accom- 
plished. If  the  abdominal  walls  are  thick  and  tense,  it  is  necessary  to 
place  the  patient  in  the  latero-prone  position,  to  use  Sims's  speculum, 

Fig.  168. 


Fritsch's  Uterine  Dilators. 


and  during  dilatation  to  fix  the  cervix  with  the  vulsellum  forceps.     In 
such  cases  the  diverging  instruments  are  preferable. 

Diverging   Instruments. — Innumerable   instruments   have  been 


Fig.  169. 


Schultze's  Dilator. 

devised  with  blades  which   diverge   and   dilate  the  uterus  when  the 
handles  are  pressed  or  screwed  together.     (See  Fig.  169.) 

Schultze's  dilator  and  Goodell's  modification  of  Ellinger's  dilator^ 
have  serrated  blades  to  prevent  them  from  slipping  out  during  the  pro- 

FiG.  170. 


Nott's  Uterine  Dilator. 

cess  of  dilatation  :  this  accident  is  much  more  liable  to  occur  with  the 
latter  instrument,  on  account  of  the  parallel  action  of  its  blades,  and 
notwithstanding  strong  counter-traction  with  the  vulsellum  forceps  it 
does  occur  in  many  cases  long  before  dilatation  can  be  completed.  The 
blades  of  the  Schultze's  dilator  diverge  in  a  fan-like  manner,  and  are 

^  See  p.  319  in  "Gynecological  Diagnosis." 


DiLAiAi'ios  nr  mi:  rri.iirs.  riolj 

tlieivfurc  a  little  more  liable  to  injure  the  uterus,  but  tlie\'  dn  iidt  >Iij) 
out,  and  are  tlieref"i)re  tu  be  I'e-erved  for  ea.-cn  in  uliieli  tlie  I'liliuiier 
iiLstruiueut  eaniiot  be  retaiue<l.  Tlie.-e  dihitors  are  <:ciierall\  too  lie;i\  \- 
to  be  inserted  until  (lie  way  lias  been  opened  by  ;i  liu|||«r  instruinent, 
like  Xott's  (>ee  V\\l,.  ITOj,  or  by  the  siiialler  Liradii.itcd  x.iind,  (  I''i^. 
IGS),  or  by   a  tent. 

Dr.  (i lell  '  of  l*liiladelj)hia  lias  been  l"orenio>t  aiiioii^  the  advocates 

of"  this  inethoij  ol' dilatation.  In  a  lar^c  experience  with  extn-ine  dila- 
tation under  ether  he  has  had  in»  fatal  roiilt  and  no  serious  inflain- 
niatory  disturbance,  lie  carries  the  <lilatation  to  three-fourths  of  an 
inch  in  the  thin-walled,  unyielding  infantile  ut<'rus,  and  to  (jue  and  a 
fourth  inches  in  other  instaneos.  In  case  of  a  ri*;id,  unyielding;,  or  thin- 
walled  uttM'us,  which  niiuht  tear  from  rai)id  expansion  of  the  dilatin<r 
blades,  it  is  better  to  eoniiuence  dilatation  with  a  s|)on<i;e  or  tupelo  tent, 
the  .softeniiiu;  influenee  of  which  renders  the  eanal  more  easily  and 
thorou;ihly  dilatable  by  the  forcible  method. 

The  dangers  are  traumatic  and  .septic,  the  Ibrmer  even  t<j  the  extent 
of  rupture  of  the  uteru.s  and  consequent  peritoniti.s,  and  death  mav 
result  from  over-distension  by  rapid  dilatation  of  a  rigid  uterus.  The 
latter  danger  i.s  preventiblc  by  antiseptics.  The  speeial  dangers  of 
dilatation  by  tents,  and  the  impossibility  of  enforcing  thorough  anti- 
sepsis in  their  use,  have  been  considered  in  a  previous  paragraph.  It 
would,  however,  be  a  fatal  mi.stake  to  suppose  that  antisepsis  deprives 
dilatation  bv  any  method  of  all  its  perils.  All  manipulations  of  this 
class,  says  Fritsch,  are  dangerous,  and  not  to  be  employed  unless  the 
indication  is  quite  clear.  Existing  pelvic  inflammation,  acute  or  chronic, 
is  a  serious  contraindication.  Indeed,  the  history  of  a  majority  of  fatal 
cases  includes  previous  cellulitis,  peritonitis,  or  metritis.  Dilatation, 
however  slight,  by  any  method,  .should  be  regarded  as  a  surgical  opera- 
tion, should  always  be  done  at  the  patient's  house,  never  at  the  office, 
and  should  lie  followed  by  rest  in  bed  for  a  time  varying  from  one  to 
seven  davs.  Forcible  dilatation  either  bv  sounds  or  bv  divertfing;  instni- 
ments  requires  an  ansesthetie,  except  when  the  dilatation  is  to  be  slight. 
If  there  be  tenderness  about  the  uterus  or  other  signs  of  inflammation, 
or  if  the  patient  has  suffered  from  a  previous  attack,  ice  should  be  kept 
over  the  hypogastrium,  quinine  should  be  given  in  full  doses,  and  opium 
according  to  the  jiain  until  the  danger  has  passcfl. 

The  special  advantages  of  each  method  of  dilatation  mav  be  sum- 
marized as  follows  : 

Incision. — Contraction  of  the  os  externum  and  lower  ])ortion  of  the 
uterine  canal  is  be.st  treated,  according  to  the  nature  of  the  case,  either 
by  Fritsch's  operation  for  enlarging  the  os  externum  In-  incision  or  by 
Schroeder's  operation  of  bilateral  incision  of  the  cervix. 

'  American  Journal  nf  Obstetric^,  18S4.  p.  1170. 


360   GENERAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

Tents. — Sponge  tents  are  the  most  dangerous,  tiipelo  least.  Lami- 
naria  lias  but  one  advantage  over  tuj^elo,  its  flexibility  and  adaptability 
to  a  tortuous  canal.  In  a  case  of  rigid  liyjDcrplastic  or  thin- walled 
cervix  not  safely  dilatable  by  rapid  means  the  tent  is  specially  indi- 
cated as  a  means  of  preparation  for  rapid  dilatation  by  graduated 
sounds  or  diverging  instruments. 

Graduated  Sounds  and  Divei^ging  Dilators  are  generally  the  safest 
and  most  eifective  means  of  dilatation,  and  should  have  the  preference 
unless  the  softening  effect  of  the  tent  is  specially  desired. 


The  Curette. 

The  curette  is  a  spoon-shaped  instrument,  fenestrated  or  non-fe- 
nestrated,  with  a  dull  or  sharp  cutting  edge,  which  may  be  introduced 
into  the  uterus,  with  or  without  previous  dilatation,  for  the  purpose  of 
scraping  away  diseased  tissue  for  diagnostic  or  remedial  purposes.  The 
instrument,  first  introduced  in  1843  by  R^camier,  has  passed  through 
many  modifications  and  received  the  severest  censure,  not  wholly  unde- 
served, on  account  of  its  disastrous  results,  among  which  are  perfora- 
tion of  the  uterus,  cellulitis,  peritonitis,  metritis,  and  septicaemia. 

The  indications  for  the  curette  are  hemorrhage  and  septicaemia,  due 
to  the  presence  of  some  intra-uterine  cause. 

The  dull  wire  curette  of  Thomas  (see  Fig.  171)  fulfils  nearly  all  the 

Fig. 171. 


Thomas's  Dull  Wire  Curette. 

indications  of  the  instrument,  and  in  suitable  cases  its  use  is  almost 
entirely  free  from  danger.  It  is  made  of  flexible  copper  wire.  The 
loop  at  its  extremity  has  slightly  flattened  but  not  cutting  edges.  Its 
shank  may  be  bent  like  a  probe  to  conform  to  the  direction  of  the 
uterine  canal,  and  whatever  the  force  applied  it  is  not  likely  to  injure 
the  sound  tissue,  while  it  easily  removes  the  soft,  friable  products  of 
hyperplastic  endometritis  called  granulations,  or  the  secundines  of  an 
abortion,  or  soft  tumors  malignant  and  benign. 

Simon's  steel  curette  (Fig.  172),  not  fenestrated,  or  Sims's  fenestrated, 
each  of  which  is  provided  with  a  sharp  cutting  edge,  should  be  reserved 
for  the  removal  of  diseased  mucous  membrane  or  of  malignant  tumors 


77//;    \-.\<;l.\.lI.    TAMI'OS.  .".01 

wliii'Ii  resist  the  dull  iiotniiiicnt.  (  'iii-cttcs  n\'  various  sizes  are  r(M|iiirci[ 
aeeordiiu'"  tn  the  aiiudiiit  to  1k'  ri'iii(tvc<l  ami  llw  size  of  the  uterine  m\- 
itv.  The  smaller  sizes  may  he  introduced  and  used  without  previous 
dilatation.       Hurini^-   tlie   operation,    wliicli    is    best    pei'l'ormed    tliroUL;li 

Kk;.  172. 


^ 


'^^^^^ 


Simon's  Sharp  Steel  Curette. 


Sims's  speeuhini,  the  eervix  is  held  bv  a  uterine  tenaeuhun.  After  all 
the  di.seased  tissue  has  been  removed  the  endometrium  should  be  wiped 
out  with  absorbent  eotton,  and  then  with  cotton  .saturated  with  Church- 
ill's tincture  of  iodine.  The  danger.s,  contraindications,  and  precautions 
are  the  same  as  in  dilatation  of  the  uterus. 


The  Vaginal  Tampon. 
The  tampon  should  fulfil  the  double  object  of  preventing  hemorrhage 
and  of  pnjdueing  such  pressure  against  the  upper  portion  of  the  vagina 
as  to  impede  the  flow  of  blood  to  the  uterus.  In  ca.ses  of  extreme  hem- 
orrhage it  often  becomes  necessary,  before  placing  the  tampon,  to  plug 
the  cervical  canal  with  cotton  saturated  with  tincture  of  iodine  or  some 
other  astringent.  This  cervical  tampon  should  be  composed  of  a  single 
piece  of  cotton,  so  that  it  may  be  easily  removed.  The  material  of  the 
tampon  should  be  cotton  made  into  pledgets  about  two  inches  square 
and  half  an  inch  thick,  and  saturated  with  a  solution  of  aliun  and 
squeezed  dry.  Its  application  through  Sims's  speculum,  which  for  this 
purpose  is  almost  indispensable,  has  been  well  described  by  Emmet. 
The  following  is  the  substance  of  his  directions :  Empty  the  bladder, 
place  the  patient  in  Sims's  position,  and  introduce  the  speculum. 
Remove  all  clots,  smear  the  vagina  thoroughly  Mith  va.>^eline  or  lard, 
which  renders  the  canal  more  distensible  and  the  packing  le.ss  painful, 
and  tends  to  retard  the  flow  of  blood  between  the  tampon  and  the 
vaginal  walls ;  then  place  a  pledget  of  cotton,  freshly  dampened  with 
a  solution  of  alum,  over  the  cervix  ;  then  roll  up  a  mass  and  place  it 
in  the  posterior  cul-de-sac,  also  on  each  side  and  in  front ;  cover  all 
this  with  a  flat  jiiece  of  cotton  ;  then  place  pledgets  around  the  cervix 
in  a  circle,  and  fill  in  the  centre ;  press  back  the  cotton  from  the  cir- 
cumference to  the  centre  with  a  stout  whalebone  or  wooden  stick  in  the 
left  hand  and  a  pair  of  dressing-forceps  in  the  right,  and  as  room  is 


362    GE^EEAL   CONSIDERATION  OF  GYNECOLOGICAL  SURGERY. 

thus  gained  fill  in  with  more  cotton.  When  the  vagina  has  been  well 
filled  press  it  firmly  back  with  the  stick  from  the  anterior  wall  toward 
the  hollow  of  the  sacrum,  and  slip  the  speculum  in  front  of  the  mass. 
As  the  speculum  is  drawn  back  bv  the  assistant  the  space  left  will 
extend  nearly  to  the  uterus.  This  is  to  be  filled  in  the  same  manner, 
and  the  speculum  repeatedly  withdrawn  and  replaced  in  front  of  the 
mass,  and  the  remaining  space  again  filled,  until  the  whole  canal  is 
firmly  packed.  Xo  violence  should  be  used,  but  by  going  around  and 
around  the  mass  and  firmly  packing  in  with  the  stick  and  the  forceps 
one  small  portion  after  another,  the  pelvic  basin  may  be  almost  entirely 
filled.  If  the  tampon  be  large,  confine  the  patient  in  bed  and  give  an 
anodyne.  Should  the  anodyne  fail  to  give  relief,  the  lower  portion  of 
the  cotton  may  be  removed.  If  there  be  retention  of  urine,  it  should 
be  drawn  Avith  an  elastic  male  catheter.  The  tampon  should  not  be 
left  longer  than  twenty-four  hours.  Before  applying  another  it  is  best 
to  wash  out  the  vagina  with  an  antiseptic  douche  and  to  relieve  the 
bowels  by  an  enema. 

Dr.  Frank  P.  Foster  ^  of  New  York  recommends  lampwick  as  an 
excellent  material  for  the  tampon,  on  account  of  ,the  ease  of  its  intro- 
duction and  removal  even  without  a  speculum,  and  on  account  of  its 
ready  absorbability.  He  says  :  "  When  the  tampon  is  to  be  removed 
the  patient  simply  makes  traction  upon  the  portion  of  wicking  that 
was  left  hanging  from  the  vulva,  and  the  mass  within  the  vagina  is 
unwound  as  the  traction  proceeds ;  consecjuently,  no  large  wad  has  to 
pass  the  vaginal  orifice  and  the  extraction  of  the  tampon  is  painless. 
Besides  the  advantage  of  its  greater  absorbent  property,  I  find  that 
wicking  is  better  adapted  to  the  easy  and  rapid  performance  of  such  a 
proceeding  as  I  have  described  than  any  of  the  other  substances  men- 
tioned, including  the  roller  bandage.  Moreover,  it  is  sometimes  desir- 
able to  tampon  the  cervical  canal,  or  to  introduce  a  medicinal  agent  into 
the  uterine  canal  in  such  manner  as  to  ensure  its  prolonged  contact  with 
the  endometrium.  For  such  purpose  an  inch  or  more  of  the  end  of 
the  wicking  may  be  stiffened  with  gelatin,  and  then,  after  having  been 
dipped  into  the  liquid  to  be  applied,  be  introduced  into  the  canal  by 
means  of  a  pair  of  dressing-forceps.  If  care  is  taken  not  to  coat  the 
whole  circumference  of  the  wicking  with  the  gelatin,  the  liquid  medic- 
ament readily  permeates  the  stiffened  wacking,  and  a  considerable  quan- 
tity of  it  may  thus  be  introduced  within  the  uterine  canal.  Enough 
more  wicking  is  then  inserted  into  the  vagina  to  act  as  a  tampon,  and 
when  this  is  removed  the  portion  originally  introduced  into  the  uterus 
comes  out  with  it." 

'^  Nexv  York  Medical  Journal,  June,  1880. 


GENERAL  THEllATKl  TICS 

13v  ALEXANDER  J.  C.  SKENE.   >I.  D.. 
Brooklyn,  N.  Y. 


A  RATIONAL  system  of  tlierapeuties  is  based  upon  a  knowledge  of 
the  various  morbid  states,  a  clear  comprcliension  of  the  uature  and 
action  of  the  ai^ents  employed  in  the  treatment  of  disease,  and  a  judi- 
cious adaptation  of  the  latter  to  the  relief  of  the  former. 

It  is  presumed  that  the  readers  of  this  work  are  familiar  with  dis- 
eases in  general  and  the  means  to  be  used  in  their  treatment.  ^ly  task, 
therefore,  is  limited  to  a  general  consideration  of  the  selection  and 
administration  of  the  most  reliable  means  to  be  employed  in  the  man- 
ay;ement  of  the  diseases  which  come  under  the  care  of  the  o:vne- 
cologist. 

The  order  in  M'hich  I  intend  to  discuss  the  several  branches  of  this 
subject  is  to  consider  very  briefly  some  of  the  chief  points  in  the  man- 
agement of  functional  derangements,  and  then  the  general  and  local 
treatment  of  the  organic  diseases  of  the  uterus  chiefly. 

The  derangements  of  menstruation,  classified  according  to  their  causes, 
are  malnutrition,  morbid  innervation,  and  organic  diseases  of  the  nutri- 
tive system  Avhich  give  rise  to  conservative  amenorrha?a.  Reference 
may  he  made  also  to  derangements  or  absence  of  the  menses  due  to  mal- 
formations and  diseases  of  the  sexual  organs. 

In  the  treatment  of  all  the  derangements  of  the  menstruation  the  one 
cardinal  })oint  must  ever  1)0  kejit  in  mind — viz.  to  remove  the  c;.iise,  be 
it  local  or  general,  upon  which  the  derangement  of  the  uterine  function 
dejKMuls. 

Anienctrrhrea  and  scanty  menstruation,  so  frequently  due  to  ansemia, 
promptly  yield  to  restorative  tonics  and  proper  food.  This  is  one  of 
the  best-establishal  facts  in  thcrajieutics.  Iron  is  of  course  the  restor- 
ative tonic  most  to  be  depended  upon  in  the  management  of  antemia. 
However,  there  are  some  ideas  regarding  the  use  of  the  diflerent  jinj)- 
arations  and  the  combinations  of  iron  with  other  remedies  which  must 
be  mentioned  in  this  connection. 

The  muriated  tincture  of  iron  is  one  of  the  oldest  and  most  reliable 
of  all  preparations,  and  answers  in  the  great  majority'  of  (uses.     It  may 


364  GENERAL   THERAPEUTICS. 

be  confidently  used  at  all  times,  except  when  there  is  some  objection 
made  on  the  part  of  the  patient  or  when  ausemia  is  associated  with 
some  other  disorder  which  demands  attention.  Sometimes  the  remedy 
disagrees  with  the  patient  or  she  fancies  she  cannot  take  it ;  then  some 
other  preparation  may  be  used. 

The  fastidious  will  take  the  tartrate  of  potassa  and  iron  in  wine,  and 
sometimes  profit  by  it,  while  others  will  take  iron  in  jiill  form  with 
great  advantage.  When  the  anaemia  is  accompanied  with  other  morbid 
states,  remedies  may  be  combined  with  iron  to  remove  these  complica- 
tions. In  subjects  whose  breathing  capacity  is  limited  the  action  of 
iron  will  be  aided  by  combining  with  it  chlorate  of  potassa,  which  is 
said  to  aid  in  the  aeration  of  the  blood.  Again,  in  torpor  of  the  liver 
muriate  of  ammonia  acts  well ;  hence  a  good  combination  for  such 
subjects  is  the  tincture  of  iron,  chlorate  of  potassa,  and  the  muriate 
of  ammonia. 

When  there  is  exhaustion  as  well  as  impaired  nutrition  of  the  ner- 
vous system  nerve-tonics  should  be  added  to  the  iron.  Strychnia  is  a 
favorite  remedy,  and  many  of  the  ready-made  tonics  of  the  present 
time  have  for  their  chief  ingredients  iron  and  strychnia.  This  remedy, 
however,  is  not  a  restorative  tonic  in  the  true  sense  of  the  term.  At 
best  it  can  only  arouse  the  nerve-energies  for  a  time,  and  hence  its  use 
should  never  be  long  continued,  neither  should  the  doses  given  in 
amenorrhoea  be  large. 

There  are  other  nerve-tonics  better  adapted  to  the  depressed  state  of 
the  nervous  system  accompanying  the  menstrual  disorders.  The  phos- 
phates have  long  had  a  reputation  in  the  list  of  the  nerve-tonics,  and 
they  should  be  combined  with  iron  whenever  called  for.  The  pyro- 
phosphate of  iron  was  at  one  time  popular,  and  deservedly  so.  Among 
the  various  preparations  of  the  phosphates,  Parrish's  compound  syrup  of 
phosphates  is  quite  equal,  if  not  greatly  superior,  to  many  of  the  fashion- 
able compounds  of  the  present  day.  Phosphorus  is  of  course  the  thing 
required,  but  it  is  difficult  to  administer.  A  solution  of  phosphorus, 
in  cod-liver  oil,  put  up  in  pills,  is  one  of  the  best  ways  of  giving  it,  but 
the  odor  and  taste  are  so  disagreeable  that  many  patients  cannot  or  will 
not  take  it. 

Some  of  the  cerebro-spinal  stimulants  act  well  in  the  menstrual  dis- 
orders due  to  depressed  and  exhausted  states  of  the  nervous  system. 
Belladonna,  cannabis  indica,  and  all  of  this  class,  when  given  in  doses 
snfficient  to  stimulate  the  nervous  system,  sometimes  appear  to  act 
favorably  in  amenorrhoea  and  scanty  menstruation.  In  their  action 
they  appear  to  sustain  the  nervous  system  when  given  in  small  and  con- 
tinued doses.  In  regard  to  belladonna,  hyoscyamus,  and  all  of  that 
class,  they  should  be  given  in  small  doses — very  much  smaller  than 
recommended  in  the  textbooks.     These  stimulants  act  best  in   those. 


OENKR. I /.  Tin:i:. i rr.VTK s.  ;j<j."> 

oases  of"  tlcprcssi" III  rrom  cxliniislinii  iVoin  ovci'-raliiiiic  when  :i~s(ici;ilc<| 
with   imjM'i'lcct    nu'iisti-iiatioii. 

'riit'i'c  is  a  larii'c  class  of  luciistnial  (Icraiiticmciits  diir  in  <lcraiit:<'(l 
iinifi'valioii  in  (he  Inrni  nl"  niidiic  cxcitciiicni,  and  not  nccc.-.-ardv 
accompanied  witli  aiitcinia.  A  .-Ironi;-  impression  mad(!  upon  tlic  ner- 
vous system  from  any  cause  snllicieut  to  jn'oduce  shock  will  arrest  the 
menstrual  liinctions  in  many  cases.  So  also  over-mental  excitation 
from  auv  cause  will,  it"  louu;  contiuued,  hav(!  the  same  eilect.  In  all 
this  class  of  oases  uorve-scdatives  are  iudicated — reuiedies  that  will 
liive  the  required  sedation  without  the  objectionable  effects  of  such  agents 
as  opium  and  chloral  hydrate.  These  should  be  in  such  cases  avoided, 
because  this  class  of  jiatients  ac({uire  the  habit  of  .takin*^  such  nerve- 
sedatives  with  extraordinary  facility. 

The  bromides  take  the  highest  rank  in  the  manajrement  of  these 
Ciises.  In  acute  cases  the  bromide  of  sodium  should  be  oiven  in  fidl 
doses  until  all  the  nervous  perturbation  is  overcome,  and  ^\■hen  this  is 
aceom})lished  it  frequently  happens  that  the  menstrual  function  will  be 
established  without  further  treatment.  The  use  of  this  remedy  should 
be  limited  to  acute  derangement  of  innervation  in  women  otherwise  in 
good  health.  AVhcnevcr  tliere  is  general  weakness  from  impaired 
nutrition  the  bromides  should  not  be  given  in  large  doses  nor  long 
continued :  enough  to  procure  quiet  sleep  (if  it  is  poasible  to  do  so 
with  bromide)  and  relieve  the  nervous  excitement  is  all  that  is  required 
ot"  this  remedy.  In  such  conditions  the  bromides  will  often  fail  and 
other  remedies  must  be  resorted  to.  A  favorite  combination  of  mine 
is  the  extracts  of  valerian,  conium,  and  lupuline  with  camjihor,  given 
in  a  capsule.  This  often  answers  the  purpose  of  a  nerve-sedative,  giv- 
ing sleep  and  a  disposition  to  rest,  which  affords  the  patient  time  and 
inclination  to  menstruate.  Valerianate  of  zinc,  valerianate  of  ammonia, 
monobromide  of  camphor,  bromide  of  zinc,  and  like  remedies  are  all 
of  some  service  in  such  cases,  and  should  be  resorted  to  when  the  other 
means  have  failed. 

The  ])ermanganate  of  potash  has  recently  been  introduced  by  Sydney 
Ringer  of  London  as  an  excitant  of  the  menstrual  function.  I  have 
used  this  remedy  in  a  number  of  cases  of  amenorrhoea,  and  have  derived 
lienefit  from  it ;  but  I  have  not  had  the  extraordinary  results  from  it 
that  would  enable  me  to  speak  in  such  strong  praise  of  it  as  many  have 
done.  At  first  I  gave  it  in  ])ill  form,  and  that  may  have  been  against 
its  success.  But  when  I  gave  it  in  solution  it  did  not  always  satisfy 
me.  One  troul)le  is  to  get  it  into  the  circulation,  it  is  such  an  easily 
decomposed  stuff.  I  have  seen  recently  that  oleate  of  manganese  is 
commended  by  Dr.  Franklin  H.  ]\[artin  in  the  JfrrJiral  Record  for 
June  27,  1885.  The  binoxide  of  manganese  has  also  been  used  in  its 
place  witli  alleged  good  residts. 


366  GENERAL   THERAPEUTICS. 

The  rule  is  that  when  all  the  conditioDs  necessary  to  menstruation 
are  restored  the  flow  will  return.  Still,  there  are  cases  of  amenorrhoea 
which  occur  with  or  without  apparent  cause,  and  persist  long  after  the 
appreciable  defects  in  general  health  have  been  overcome.  In  such 
cases  we  seek  for  remedies  that  will  act  directly  upon  the  sexual  organs 
to  re-establish  their  function  if  entirely  absent,  or  to  increase  the  fl(jw 
if  it  is  deficient  in  quantity.  The  agents  generally  used  for  this  pur- 
pose are  sabina,  aloes,  caulophyllura,  myrrha,  cimicifuga,  tanacetum, 
cantharides,  and  guaiac.  The  action  of  tliese  remedies  is  to  produce 
stimulation  and  irritation  of  the  mucous  membrane  of  the  alimentary 
canal,  and  it  may  be  presumed  that  a  similar  effect,  though  in  a  less 
degree,  is  produced  upon  the  uterus. 

The  congestion  of  the  pelvic  organs  caused  by  these  drugs  may  act 
as  an  exciting  cause  of  menstruation  if  they  are  given  at  a  time  when 
there  is  a  predisposition  to  menstruate  and  the  local  and  general  con- 
ditions necessary  to  menstruation  have  been  established.  They  are  cer- 
tainly worse  than  useless  when  given  in  cases  of  amenorrhoea  due  to  any 
constitutional  or  local  affection,  such  as  anaemia,  deranged  innervation, 
and  disease  of  the  uterus  or  ovaries. 

There  is  also  great  difficultv  in  estimatino;  the  value  of  the  so-called 
emmenagogues,  because  of  the  fact  that  the  menstrual  function  will 
recur  in  the  great  majority  of  cases  when  the  causes  of  the  amenorrhoea 
have  been  removed.  Therefore,  when  emmenagogues  are  given  and 
the  menstrual  flow  is  established,  it  is  not  sufficient  proof  that  the  medi- 
cines used  have  produced  the  results  observed.  Again,  I  have  observed 
that  in  cases  of  amenorrhoea  in  which  no  cause  could  be  discovered  the 
so-called  emmenagogues  have  failed  to  restore  the  menses.  They  are 
agents  v.hich  are  capable  of  doing  harm  by  deranging  the  digestive 
organs,  and  hence  I  very  seldom  use  them ;  and  from  all  that  I  can 
learn  of  the  practice  of  others,  they  are  not  so  frequently  resorted  to 
as  formerly,  and  there  is  reason  to  believe  that  they  will  soon  fall  out 
of  use  entirely. 

There  are  other  agents  which  have  been  used  to  promote  the  men- 
strual flow  in  cases  where  the  amenorrhoea  has  remained  after  the  gen- 
eral condition  of  the  patient  has  been  restored  to  health  and  the  flow 
has  not  returned.  Of  these  agents  it  may  be  said  that  they  are  not 
likely  to  do  harm,  and  their  recognized  general  therapeutical  action 
suggests  at  least  the  possibility  of  their  being  useful.  These  are  the 
diffusible  stimulants,  like  alcohol,  ammonia,  camphor,  chloric  ether, 
and  acetate  of  ammonia.. 

There  are  two  conditions  in  which  these  remedies  are  indicated.  The 
first  is  where  the  subject  has  been  exposed  to  cold  at  the  time  w'hen  the 
menstrual  flow  should  ap]iear,  but  does  not.  AVe  counteract  the  effects 
of  the  cold  and  equalize  the  circulation  by  means  of  a  warm  bath,  and 


ai:si:i:. i  /.  tiii:i:a  i'EUTK  x  307 

then  ainiinuiia  with  caiiiplinr,  a  small  (l(is<'  of  warm  \i\\\  or  wliisUcy 
juiiicli,  <»r  tin-  acetate  of  aiiimuiiia  will  olteii  ^ive  ^<»o<l  results.  To  tlu^ 
otlw'r  clas^  heloiiir  those  who  ha\e  >\  liiptoliis  of  a  leildeliev  to  liieiistril- 

ati' — /.  f.  have  a  menstrual  molimen,  hut  the  flow  does  not  appear.  Iti 
sueh  eases  the  remedies  referred  to  may  he  ••m|»loyed  with  advantajre. 
In  those  of  full  hal)it  aleohol  -hoidd  he  avoided.  in  -ueli  eiLses  the 
ammonia  and  camphor  will  act  hest. 
,  In  all  countries  where  malarial  poison  prevails  deranticil  menstruation 
is  frecpiently  e.vperienced  :  the  effect  ol' thi-  miasm  ujion  the  lunetion  of 
the  uterus  is  manifest  in  many  ways.  The  ana-mia  which  so  fi-e<juently 
ocelli's  in  malarial  })oisonin<5  produces  ameiiorrho'a.  The  elVect  <tf  the 
poison  on  the  nervous  system  gives  a  like  result.  Chronic  malarial 
poisoniiiiT,  with  morhid  chanj^es  in  the  abdominal  viscera,  inHuenees 
menstruation  in  a  marked  degree,  Anienorrhfea  is  observe<l  in  these 
sui)jects  occasionally,  hut  menorrhagia  is  perhaps  more  common. 

In  all  cases  arising  from  this  common  cause  quinine  and  arsenic  are 
the  agents  to  dej)en(l  ui)on.  In  cases  of  long  standing  with  engorge- 
ment of  the  abdominal  viscera  and  enlargement  of  the  spleen  and 
liver  an  occasional  dose  of  mercury  aids  greatly  in  the  treiitment. 
Finally,  when  all  the  causes  have  been  removed  and  the  menstrual 
function  is  not  established,  and  the  means  usually  employed  to  restore 
it  have  failed,  electricity  is  well  worthy  of  a  trial.  The  interrupted 
current  is  said  to  be  the  most  valual^le  form  of  the  electric  treatment. 

General  or  central  faradization  may  be  tried,  and  if  this  fails  the 
current  should  be  passed  through  the  pelvis,  one  electrode  Ijeing  placed 
over  the  sacrum  and  the  other  over  the  pubes.  The  l)est  way  of  all  is 
to  pa.ss  one  electrode  into  the  uterus  and  the  other  over  the  .sacrum 
and  pul)cs  alternately.  But  this  method  is  seldom  practicable  in  the 
unmarried, 

Xew  impressions  fnjni  change  of  surroundings  are  often  of  great 
value  in  obstinate  cases.  Change  of  air  gives  increased  vigor  to  the 
nutritive  functions,  and  new  subjects  of  interest  and  new  associations 
are  marked  stimulants  to  the  brain  and  nervous  system;  all  of  which 
favor  the  highest  functional  activity  of  the  uterus. 

The  CoiiHiitutional  and  Local  Treatment  of  Orr/anic  Diseases  of  the 
Serual  Orr/ans,  especiaUy  the  Zleriis. — On  this  subject  there  is  possibly 
less  harmony  of  opinion  and  practice  among  g^mecologists  than  there  is 
in  reg-ard  to  the  foregoing  subject.  Yet  all  know  xery  well  that  local 
diseases,  ormnic  as  well  as  functional,  are  lar^elv  under  the  control  of 
constitutional  medication. 

The  sexual  organs  being  dependent  upon  the  general  nutritive  system 
for  su])port  and  the  general  nervous  svstom  for  innervation,  it  follows 
that  through  this  relationship  they  are  dependent  in  health  and  disease, 
and  that  anv  marked  defect  in  the  general  health  must  act  to  the  injurA' 


368  GENERAL   THERAPEUTICS. 

of  the  sexual  organs.  It  is  also  clearly  apparent  that  to  affect  the  sex- 
ual organs  with  therapeutic  agents  we  must  often  take  the  nutritive  and 
nervous  systems  as  the  channels  through  which  to  reach  them. 

There  are  a  vast  number  of  ways  by  which  the  general  organization 
works  to  the  detriment  of  the  sexual  organs,  and  in  the  jDractice  of 
gynecology  the  general  health  must  at  all  times  be  looked  after,  both 
in  connection  with  the  causation  and  treatment  of  uterine  and  ovarian 
diseases.  It  is  also  well  to  keep  in  mind  that  constitutional  remedies 
reach  and  act  upon  the  sexual  organs  through  both  the  nutritive 
and  nervous  systems.  Owing  to  this  correlationship  of  the  general 
organization  and  the  sexual  system  the  remedies  employed  l)y  the  gyne- 
cologist may  be  classified  as  follows :  First,  remedies  which  act  indi- 
rectly upon  the  sexual  organs  by  modifying  the  general  nutrition ;  sec- 
ond, remedies  which  act  through  the  nervous  system ;  third,  remedies 
which  act  especially  upon  the  sexual  organs,  either  through  the  circu- 
lation or  nervous  system ;  fourth,  agents  used  locally  which  influence 
morbid  states  of  the  sexual  orrans. 

Under  the  first  head  may  be  classed  all  agents  which  are  capable  of 
improving  general  nutrition.  This  embraces  a  field  altogether  beyond 
the  scope  of  this  work,  and  hence  I  must  limit  my  labors  to  the  consid- 
eration of  the  derangements  of  nutrition  most  commonly  seen  in  con- 
nection with  diseases  of  the  sexual  organs,  and  more  especially  to  those 
functional  disturbances  of  the  nervous  svstem  and  digestive  org^ans 
caused  by,  or  at  least  aggravated  by,  uterine  and  ovarian  diseases. 
Prominent  among  these  will  be  found  impaired  appetite  and  constipa- 
tion. The  loss  of  desire  for  food  or  a  capricious  appetite  may  be  wholly 
due  to  derangement  of  the  nervous  system,  the  stomach  itself  being 
free  from  organic  disease. 

If  this  functional  disturbance  exists  long,  gastric  catarrh  is  likely  to 
come  in  due  time.  The  former  may  usually  be  distinguished  by  the 
fact  that  the  appetite  is  capricious,  at  times  good  and  at  other  times 
poor.  The  tongue  is  not  always  coated,  but  more  often  light  red  and 
the  papillse  prominent.  In  the  latter  (catarrh)  there  is  usually  a  con- 
stant loathing  or  dislike  for  food,  and  the  tongue  has  the  swollen  and 
coated  appearance  characteristic  of  that  disease. 

In  the  management  of  either  form  of  the  gastric  disorder  the  qtian- 
tity  and  character  of  food  are  of  primary  importance.  Full  details  of 
the  dietetics  of  this  class  of  cases  must  be  obtained  from  works  on  the 
2)ractice  of  medicine.     A  word  or  two  may,  however,  be  admissible. 

As  a  rule,  the  likes  and  dislikes  of  the  patient  regarding  food  should 
be  respected,  unless  in  cases  where  the  nervous  system  is  markedly  per- 
verted and  the  fact  is  manifested  by  unreasonable  capriciousness.  In 
order  to  get  a  beginning  to  improve  great  advantage  may  be  obtained 
by  using  the  digested  foods.     Peptonized  milk,  gruel,  and  beef  should 


genkhal  Tiii:iiAi'j-:uTrcs.  30f) 

be  tried.  Lately  I  have  hecii  able  to  iioiirisli  some  of  <lie  most  ohsti- 
nati'  etuies  with  the  jircparation  known  as  "  Fairchihl's  liumani/.ed 
milk."  This  is  intended  lor  iiilants,  hnt  it  has  proved  of  great  service 
in  l)('<;innin<;-  the  ti'eatmcnt  of  many  eases  of  feeble  indif^cstion. 

l'\)reed  feedin«;-  has  been  j^reatly  in  vo<^ne  of  late,and  it  luus  its  advan- 
tage's. The  method  is  to  bei^-in  by  givin<>;  small  doses  of  food  at  short 
intervals,  and  increase  the  (jnantity  regnlarly  until  the  capacity  of  tak- 
ini;;  an  abundance  is  developed.  The  system  is  an  admirable  one,  and 
is  es[)eeially  suited  to  the  cases  of  gastric  neurosis  and  reflex  gastric  dis- 
t)rders.  It  has  its  limits,  however,  as  there  are  cases  where  it  seems  to 
be  unsatisfactory.  As  soon  as  the  patient  has  improved  sufficiently  in 
the  power  of  digestion  a  liberal  and  varied  quantity  of  food  should  be 

The  medicinal  agents  to  be  employed  to  aid  digestion  and  create  an 
appetite  are  of  two  classes — sedative  and  tonic.  Gastric  sedatives  will 
quiet  irritation  and  ira])rovo  the  appetite  in  certain  cases.  Of  these, 
bismuth,  oxalate  of  cerium,  and  hydrocyanic  acid  are  the  most  reliable. 
The  oxalate  of  cerium  should  be  given  in  larger  doses  than  the  books 
direct.  Five  or  six  grains  before  meals  are  a  sufficient  dose.  These 
remedies  should  be  given  half  an  hour  before  meals. 

The  tonics  are  the  vegetable  bitters,  the  preferable  ones  being  colura- 
bo,  quassia,  and  cedron.  The  drachm  doses  of  these  bitter  tinctin-es 
generally  given  do  not  act  well  in  the  cases  under  consideration.  Such 
doses  contain  too  much  alcohol  for  irritable  stomachs  unless  largely 
diluted,  and  then  the  quantity  is  too  great.  Half  a  drachm,  or  even 
less,  in  a  little  warm  water  is  more  efficient  and  acceptable.  Two  or 
three  drops  of  nux  vomica  in  a  small  wineglass  of  warm  water  acts 
well  with  many.  Two  drops  of  wine  of  ipecac,  added  to  the  nux  vom- 
ica makes  a  most  valuable  combination.  Four  drops  of  fluid  extract 
of  cedron  given  in  water  is  also  of  great  value  in  giving  an  ajijietite. 
The  bitter  is  clear,  well  defined,  and  passes  away  very  soon,  leaving  an 
agreeable  taste  in  the  mouth. 

]\Iuch  may  be  done  by  a  competent  nurse  who  understands  liow  to 
offer  tempting  articles  of  diet. 

When  food  is  being  taken  in  fair  quantities  only  half  the  battle  is 
won  in  many  cases.  The  digestion  may  be  labored  and  attended  with 
much  distress — in  some  cases  immediately  after  eating,  in  othei*s  an  hour 
or  two  after.  INIuch  of  this  may  be  avoided  by  giving  food  that  is  easily 
digested.  If  this  fails,  the  digested  foods  ali-eady  referred  to  should 
be  given.  Pepsin  helps  this  labored  digestion  in  certain  ca.ses,  while  in 
othei*s  it  is  useless.  When  pepsin  alone  fails,  I  have  combined  with  it 
lactic  acid  and  some  aromatic,  like  tincture  of  cardamom.  This  is  given 
after  the  meal  in  hot  water. 

The  disagreeable  behavior  of  the  stomach  is  often  greatly  aggravated 

Vol.  I.— 24 


370  GENERAL  THERAPEUTICS. 

by  the  state  of  the  bowels.  Indeed,  many  times  I  observe  that  when 
the  bowels  are  made  to  act  properly  the  stomach,  which  has  been  out 
of  order,  takes  up  its  duties  at  once. 

Constipation  of  the  bowels  is  an  almost  ever-present  state  in  those 
who  have  disease  of  the  sexual  organs.  This  is  caused  either  by 
deranged  secretion  of  the  alimentary  canal,  impaired  nmscular  action, 
deranged  innervation,  or  all  three  together.  The  condition  of  the 
tongue  and  the  character  of  the  discharges  will  show  imperfect  secretion, 
and  this  can  best  be  relieved  by  beginning  with  a  dose  or  two  of  mer- 
cury. A  dose  of  blue  mass  with  a  grain  of  ipecac,  at  night,  followed 
if  need  be  by  some  gentle  laxative,  will  often  give  good  results.  For 
those  who  alternate  between  constipation  and  diarrhoea  a  favorite  pre- 
scription is  blue  mass,  calcined  magnesia,  aromatic  syrup  of  rhubarb, 
glycerin,  and  peppermint-water. 

To  keep  the  bowels  in  order  after  one  or  more  doses  of  these  altera- 
tive cathartics  the  mineral  waters,  natural  or  artificial,  will  answer  well 
for  those  whose  secretions  are  retarded.  In  the  use  of  these  there  are 
two  rules  which  ought  to  be  observed :  First,  to  give  the  water  at  least 
one  hour  before  meal-time,  the  morning  being  preferable  if  the  patient 
can  take  it  then ;  and  second,  to  select  by  trial  the  water  which  suits  the 
case  in  hand.  Practitioners  are  apt  to  use  some  favorite  water  for  all 
cases,  while  the  rational  method  is  to  select  from  the  many  the  one 
which  gives  the  desired  results  in  severe  cases. 

When  the  constipation  is  due  to  muscular  and  nervous  debility, 
mineral  waters  and  saline  laxatives  rarely  agree  well.  They  cause 
flatulence,  pain,  and  occasionally  nausea.  In  such  conditions  tonic 
laxatives  are  required.  In  the  use  of  these  there  are  some  rules  which 
should  be  carefully  observed.  They  should  be  given  in  small  doses, 
repeated  often  enough  to  give  the  desired  effect  and  no  more,  and  they 
should  be  continued  until  the  habit  of  constipation  is  completely  broken 
up,  and  resumed  upon  the  first  indication  that  the  trouble  is  returning. 
If  the  adaptation  of  the  remedies  is  right,  the  doses  can  be  gradually 
diminished  in  quantity  and  frequency,  in  place  of  having  to  increase 
the  medicine  to  get  the  desired  effect. 

Belladonna  stands  at  the  head  of  the  list  of  agents  in  the  treatment 
of  constipation  occurring  in  gynecological  cases.  If  given  alone  in 
small  doses,  often  repeated,  it  will  answer  in  some  cases.  It  is  of  course 
seldom  given  alone,  but  in  combination  with  other  laxatives. 

Nux  vomica  is  often  employed,  but  it  is  objectionable.  It  acts  only 
for  the  time,  and  if  continued  long  it  loses  its  effect,  requiring  a  larger 
dose  to  be  given  in  order  to  obtain  any  effect  at  all.  The  most  that  can 
be  said  of  it  in  the  management  of  constipation  is  that  it  may  be  useful 
at  the  beginning  of  the  treatment  to  give  the  patient  a  start  in  the 
right  direction  in  cases  of  marked  debility. 


GENERAL   THERAPEUTICS.  .371 

One  of  the  most  reliable  coinbiiiations  that  I  have  found  is  one  f^raiu 
of  sulphate  of  (jiiiiiiiie,  one-tenth  of  a  <rrain  of  the  extract  of  Ix'lla- 
(lonna,  and  half  a  <j;rain  of  tiic  compound  extract  of  colcK-ynth,  made 
into  a  pill.  One  of  these  given  with  each  meal  has  helped  more  cases 
than  any  other  prescrij)tion.  As  the  patient  jrains  strcn<^th  tlu;  munlx'r 
ol"  doses  can  he  ri'dnceil  to  two  (jr  one  a  diiy,  and  linallv  half  of  a  pill 
every  day  or  every  seeoud  day. 

In  cases  of  amenorrhea  or  scanty  menstruation  the  a(picous  extract  of 
aloes  may  he  used  in  place  of  the  colocynth,  a  (piarter  of  a  grain  usually 
being  sullicient.  When  pills  are  objectionable  to  the  patient,  the  fluid 
extract  of  podophyllum,  one  or  two  dro[)s,  tincture  of  colocynth,  six 
drops,  and  fluid  extrac-t  of  belladonna,  one-third  of  a  minim,  should  be 
given  after  meals  in  a  little  glycerin  and  some  aromatic  which  is  agree- 
able, like  pe|)j)ermint-water  or  cardamom.  The  compound  licorice 
powder  should  not  be  forgotten.  A  teaspoonful  of  this  prej)aration, 
if  carefully  prepared  by  being  thoroughly  pulverized  and  mixed  and 
given  at  bed-time,  will  do  well  in  many  cases. 

We  now  come  to  the  consideration  of  the  therapeutic  agents  which 
act  upon  the  sexual  organs  through  the  ultimate  general  nutrition. 
Some  of  these  agents  act  through  the  circulation  and  innervation,  nifKl- 
ifying  the  state  or  quantity  of  the  blood  which  supplies  the  sexual 
organs,  thereby  affecting  their  condition  and  action.  The  type  of  this 
cliiss  is  ergot.  This  agent  is  well  known  to  possess  very  extraordinary 
power  to  excite  muscular  action  in  the  uterus,  but  its  greatest  value  is 
limited  to  obstetric  practice.  There  it  is  the  most  certain  and  reliable 
of  all  medicinal  agents  in  its  uniform  action  under  given  circumstances. 
It  is  far  from  being  so  useful  in  the  practice  of  gynecologv.  Muscular 
contraction  of  the  uterus  can  only  be  possible  when  the  organ  is  devel- 
oped either  by  gestation  or  intra-uterine  neoplasms ;  hence  ergot  is  not 
often  efficient  in  disorders  of  the  uterus. 

It  has  been  claimed  that  ergot,  by  causing  contraction  of  the  mus- 
cular walls  of  the  blood-vessels,  is  valuable  in  all  congested  states  of 
the  uterus,  but,  practically,  this  is  not  of  much  account.  It  is  true 
that  the  ergot  causes  contraction  of  the  blood-vessels  generally,  but  in 
order  to  make  it  of  much  value  in  local  congestions  it  requires  to  be 
given  in  large  doses  and  long  continued,  so  that  long  before  much 
benefit  could  be  gained  in  disease  of  the  uterus  its  constitutional  effects 
become  so  marked  that  it  has  to  be  suspended. 

Practically,  then,  its  use  in  gynecology  is  limital  mostly  to  cases  of 
intra-uterine  growths  where  it  is  desirable  to  cause  contraction  of  the 
uterus  in  the  hope  of  arresting  their  growth  or  expelling  them,  and  in 
subinvolution  of  the  uterus,  where  the  object  is  to  cause  active  contrac- 
tion of  the  uterus  in  the  hope  of  stimulating  the  process  of  involution. 

When  the  uterus  after  confinement  remains  large,  soft,  and  vascular, 


372  GENERAL   THERAPEUTICS. 

ergot  does  appear  to  have  some  effect  in  condensing  the  tissues  and 
lessening  the  congestion.  Still,  granting  all  this,  ergot  is  not  sufficient 
alone  to  complete  involution  in  all  cases,  but  it  may  be  a  valuable  aid. 

Alteratives  which  favorably  influence  general  nutrition  often  act 
indirectly  upon  diseases  of  the  sexual  organs.  The  principal  remedies 
of  this  class  are  mercury,  iodine,  and  arsenic.  They  are  of  the  most 
service  in  overcoming  the  evil  results  of  the  products  of  bygone  inflam- 
mations, such  as  cellulitis  and  peritonitis,  the  latter  especially.  They 
are  perhaps  most  efficacious  in  ovarian  inflammations  of  a  sul^acute 
character.  They  have  been  used  also  in  endometritis,  but  they  do  not 
seem  to  accomplish  much  in  that  affection. 

To  favor  the  absorption  of  the  products  of  pelvic  cellulitis  and  peri- 
tonitis the  bichloride  of  mercury,  combined  with  iron  when  necessary, 
has  been  commended,  and  no  doubt  it  is  of  great  service.  After  using 
it  for  a  time  it  may  be  followed  by  the  iodide  of  sodium  if  the  general 
nutrition  permits  it.  The  iodide  of  iron  will  answer  better  when  iron 
is  indicated. 

The  selection  of  these  agents  should  be  made  according  to  the  condi- 
tion of  the  patient  of  course.  When  general  disintegration  is  sluggish 
and  there  is  much  flesh,  the  mercury,  followed  by  iodine,  generally  is 
best,  and  when  there  is  ansemia  the  iodide  of  iron  should  have  the 
preference.  To  be  effectual  these  remedies  should  be  continued  for  a 
Ions:  time.  A  similar  course  of  medication  is  indicated  in  old  inflam- 
matory  diseases  of  the  ovaries  and  Fallopian  tubes. 

Chloride  of  gold  has  recently  been  commended  in  diseases  of  the 
ovaries.  I  presume  it  should  be  classed  among  the  alteratives,  but  I 
have  not  seen  any  effects  from  it  that  would  warrant  my  indorsing  it, 
neither  have  I  heard  any  very  reliable  records  in  its  favor. 

In  regard  to  arsenic,  its  well-known  effects  upon  the  nutrition  of  the 
skin  and  mucous  membranes  entitle  it  to  consideration  in  the  treatment 
of  obstinate  inflammatory  diseases  of  the  uterus  and  Fallopian  tubes. 
It  should  be  given  in  small  doses  (two  or  three  drops  of  Fowler's  solu- 
tion) and  continued  for  a  long  time.  When  given  in  this  way  it  will 
apparently  improve  the  nutrition  of  the  mucous  membrane  of  the 
uterus,  judging  from  my  observations  in  the  management  of  cases 
of  obstinate  cervical  catarrh  and  membranous  dysmenorrhcea. 

There  is  another  class  of  remedies — quite  a  large  one — which  act 
mostly  through  the  nervous  system,  and  upon  which  the  gynecologist 
greatly  relies.  This  class  may  be  subdivided  into  nerve-tonics  and 
sedatives.  Of  those  classed  as  tonics,  some  may  be  considered  as  stim- 
ulants by  therapeutists,  but  it  will  suffice  for  the  present  purpose  to  say 
that  under  the  head  of  tonics  I  shall  class  all  those  that  temporarily  or 
permanently  increase  nerve-force.  Nux  vomica  is  an  agent  which  acts 
well  in  cases  of  marked  debility,  and  is  often  quite  effectual  in  cases  in 


CKSKUM    TIIF.llM'FJ'TICS.  ?u\ 

whicli  there  is  m'licnil  weakness  ol'  tlic  nervous  system  due  to  ut«riii(! 
or  ovarian  disejtses.  It  is  elaiineil  by  some  to  exert  :i  marked  ionic 
ellect  ii|»nn  the  sexual  oriT'i"'^,  i»nd  Ma  ett'eet  us  a  general  t«jnie  is  I'ully 
un(K'i-stoo(L  It  is  only  temporary  in  its  elleets,  howrvcr,  and  it"  lon^ 
eontinued  proves  injurious.  If  »riv<'u  tor  a  len<ith  ol'  time,  it  is 
ohserve<l  that  laijicr  doses  are  neeessary  to  jj;ive  the  desired  ellect,  and 
when  the  medicine  is  withdrawn  a  lowering;  ot"  the  nerve-force  takes 
place.  In  this  it  resembles  in  its  ac-tiou  the  alcoholic  stimulants.  As 
a  remedv,  then,  it  is  oidy  to  be  used  at  the  bejjjinnini;  of  the  treiitment 
to  sustain  the  patient  until  more  permanent  restoratives  have  had  time 
to  build  up  the  strenirth.  To  start  the  ease  in  the  way  of  improve- 
ment is  the  chief  otfiee  of  this  remedy. 

Belladonna  and  a«;ents  belonjijing  to  that  class,  when  given  in  small 
doses  at  regular  intervals,  exert  a  decided  tonie  influence,  especially 
upon  the  organic  nervous  system,  while  at  the  same  time  the  eifect 
upon  the  sexual  organs  is  slightly  tonie  and  sedative.  General  nutri- 
tion is  aided  by  them,  and  patients  will  often  acquire  better  spirits  and 
sleep  better  while  taking  them. 

Hydrobromide  of  hyoseiue  is  a  new  remedy,  which  acts  in  a  way 
similar  to  belladonna,  and  is  even  more  effieient.  When  given  in  doses 
of  the  one-hundredth  of  a  grain,  more  or  less  according  to  tlie  case,  it 
gives  an  improved  tone  to  the  nervous  system,  improves  the  capillary 
circulation,  and  relieves  some  of  the  wandering,  ill-defined  pains  so 
commonly  associated  with  diseases  of  the  uterus  and  ovaries. 

Zinc  and  phosphorus  represent  the  class  of  nerve-tonics  Avhich  aid  in 
restoring  the  nervous  system  to  a  better  state,  and  it  may  be  said  of  all 
these  that  so  ftir  as  they  improve  the  general  system,  just  so  far  do  they 
aid  in  relievino-  diseases  of  the  sexual  organs. 

Quinine  is  an  agent  -worthy  of  the  special  attention  of  the  gynecol- 
ogist. It  is  well  known  that  quinine  will  stimulate  uterine  contrac- 
tions during  labor  in  case  the  nervous  system  becomes  exhausted,  and 
presumably  it  may  improve  local  innervation  in  disease.  It  is  also  a 
valuable  remedy  in  cases  of  neuralgic  pains  in  the  pelvis.  In  view  of 
thes2  facts  it  is  reasonable  to  suppose  that  its  action  upon  the  pelvic 
organs  may  be  more  than  that  of  the  ordinary  tonics.  At  any  rate, 
as  a  {general  tonic  it  ranks  among;  the  hiijhest  in  the  manatrement  of 
uterine  and  ovarian  diseases. 

Electricity  has  been  more  urgently  commended  perhaps  than  any 
other  agent  in  the  practice  of  gynecology.  After  carefully  examining 
the  testimony  given  in  our  literature,  and  making  such  clinical  obser- 
vations as  I  could  regarding  electricity,  I  have  come  to  the  conclusion 
that  when  used  generally  it  is  capable  of  improving  nutrition,  and  in 
some  cases  it  quiets  nervous  irritation,  and  the  sexual  organs  come  in 
for  their  share  of  the  general  improvement ;  but  general  faradization 


374  GENERAL  THERAPEUTICS, 

or  galvanization  has  no  direct  or  specific  effect  when  used  in  this  way. 
Regarding  the  local  effects  of  electricity  something  will  be  said  far- 
ther on. 

Sedatives  are  so  frequently  called  for  in  the  practice  of  gynecology 
that  the  subject  requires  its  full  share  of  attention.  In  view  of  the 
suffering  of  those  who  have  diseases  of  tlie  sexual  organs,  the  practi- 
tioner naturally  turns  to  opium  as  the  most  potent  remedy,  but  in  this 
branch  of  practice  it  is  often  the  most  disastrous  in  the  ultimate  results 
of  its  use. 

In  acute  disease,  like  pelvic  peritonitis  and  ovaritis,  opium  is  the 
remedy  of  most  value,  but  in  the  less  acute  affections  it  is  seldom  cura- 
tive and  nearly  always  dangerous — dangerous  because  of  the  great 
facility  with  which  this  class  of  patients  acquire  the  opium  habit.  No 
remedy  can  be  more  gratifying  to  both  patient  and  physician  in  its 
immediate  results ;  but  it  relieves  only,  does  not  cure  in  many  cases, 
and  therefore  should  not  be  used  when  it  can  be  avoided. 

A  similar  though  less  severe  verdict  may  be  rendered  in  regard  to 
alcoholic  stimulants.  These  are  seldom  well  borne  by  patients  with 
diseases  of  the  pelvic  organs,  and  hence  there  is  less  danger  in  pre- 
scribing them,  because  there  is  less  likelihood  of  patients  acquiring 
an  abnormal  desire  for  them. 

Chloral  hydrate  may  be  mentioned  in  this  connection,  only  to  suggest 
caution  regarding  its  use  by  the  gynecologist.  The  most  that  it  can  do 
is  to  produce  sleep.  It  does  not  in  small  doses  relieve  pain  as  opium 
does,  and,  more  than  that,  chloral  is  more  liable  to  produce  irritation 
of  the  sexual  organs  than  opium.  Several  patients  who  have  tried 
opium  and  chloral  to  ease  their  sufferings  have  told  me  that  chloral 
caused  sexual  excitation,  while  opium  subdued  it. 

Bromide  of  sodium  is  the  great  sedative  in  the  practice  of  the  gyne- 
cologist. It  not  only  relieves  much  of  the  suffering,  but  it  has,  through 
its  sedative  effect,  a  curative  influence  in  many  of  the  diseases  of  the 
sexual  organs.  By  relieving  the  nervous  excitation  and  irritability  it 
lessens  the  congestion  of  the  pelvic  organs,  and  hence  tends  to  relieve 
many  of  the  inflammatory  diseases  and  functional  derangements.  There 
are  two  ways  of  using  bromides,  according  to  the  effect  desired — the 
one  to  break  up  nervous  symptoms,  the  other  to  induce  sleep.  Full 
doses,  repeated  until  the  specific  effects  are  produced,  should  be  given 
when  the  object  is  to  break  up  a  train  of  nervous  symptoms  due  to  dis- 
ease of  the  pelvic  organs.  When  this  is  accomplished  the  patient  will 
generally  emerge  from  the  effects  of  the  bromide  in  a  quieter  and  better 
condition  to  respond  to  the  general  restorative  treatment. 

In  some  of  the  weak,  nervous  cases  one  may  be  at  times  afraid  to 
push  the  bromides  very  far,  for  fear  that  the  prostrating  effects  might 
prove  dangerous.     Caution  in  this  is  wise  and  necessary,  and  yet  the 


GFXFRAL    TUKUArET'TTCS.  370 

puticnt  must  bo  l)r(niii,lit  imkIct  llic  rcuu'dy  to  <;:c't  the  full  honcfit,  'I'o 
acroiiiplish  the  «j:;(kk1  and  avoid  the  danger  small  doses  of  mix  V(»miea 
should  i>e  eomhiued  with  the  bromide.  Dif^italis  also  may  be  added  if 
the  heart-aetiou  is  weak. 

\\'hile  advoeatiug'  tlu;  lilxTal  use  of"  bromide;  I  would  sav  that  it 
should  not  be  lon<r  continued.  1  rarely  give  this  (b*u<r  ionj^er  than  a 
week  or  two,  except  it  may  be  one  dose  in  the  aiternoon  and  evening 
to  j)rolong  the  night's  sleep. 

AVhen  bromide  is  not  well  borne  or  docs  not  give  the  desired  effect, 
cannabis  indica  may  be  tried.  Conium  also  does  well,  and  may  be 
combined  with  camphor,  croton  chloral,  lupulin,  belladonna,  ttsafretida, 
and  castor,  but  they  all  may  be  cousitlered  a.s  substitutes  to  be  used  in 
rare  cases  when  the  bromides  fail. 

Next  to  the  bromides  among  nerve-sedatives,  and  perhaps  first  among 
them,  is  massage.  The  introduction  of  this  treatment  into  rational 
therapeutics  was  a  most  valuable  contribution.  It  is  employed  usually 
to  aid  Nutrition,  and  for  this  purpose  it  is  of  great  benefit,  but  it  is  an 
excellent  nerve-sedative.  A  skilful  nurse  can  by  systematic  manipula- 
tion soothe  the  tegumentary  nerves  and  produce  that  normal  tiredness 
which  invites  rest  and  sleep.  That  which  used  to  be  the  property  of 
ignorant  and  designing  magnetic  rubbers  is  now  modified  and  adapted 
to  rational  use.  It  is  a  "  stone  which  the  builders  rejected  "  for  a  time, 
but  now  fills  an  important  place  in  therapeutics. 

This  massage  is  true  jDassive  exercise,  the  only  way  that  exercise  can 
be  given  without  exhausting  or  taxing  the  nerve-centres.  By  this 
means  the  muscular  system  can  be  toned  down  to  the  condition  adapted 
to  normal  rest,  and  a  like  effect  appears  to  be  produced  upon  the  si)inal 
nerves.  This  therapeutic  agent  is  of  so  much  importance  that  reference 
will  be  again  made  to  it  as  we  proceed.  This  part  of  the  subject  would 
be  incomplete  without  mentioning  electricity.  That  this  agent  is  useful 
most  practitioners  will  acknowledge.  In  my  own  practice  I  have  not 
been  satisfied  that  it  accomplishes  much,  excepting  in  a  certain  class  of 
cases. 

Those  who  suffer  from  functional  derangements  of  the  sexual  organs 
and  nervous  system  because  of  imperfect  development  or  misdirected 
and  unoccupied  nerve-energies — in  short,  spoiled  girls  and  women — 
require  a  very  diflferent  course  of  treatment  from  those  who  suffer  from 
more  definite  diseases.  The  great  object  is  to  find  mental  and  physical 
employment  for  them  which  will  turn  their  attention  away  from  them- 
selves. Here  also  isolation  is  an  important  factor,  but  it  is  not  for  the 
sake  of  rest,  but  change  of  occupation. 

To  remove  such  cases  from  the  influence  of  kind  but  unwise  friends, 
and  place  them  in  the  more  wholesome  society'  of  a  nuree  and  physician, 
is  a  great  gain.     And  then  their  whole  time  should  be  profitably  occu- 


376  GENERAL   THERAPEUTICS. 

piecl.  A  portion  of  the  clay  should  be  devoted  to  the  Turkish  or 
Roman  bath,  and  if  there  is  a  well-defined  hysterical  element  present, 
the  cold  pack,  shower-bath,  and  needle-bath  may  all  be  tried  in  turn. 
In  the  external  use  of  water  the  rule  is  warm  water  for  the  weak  and 
nervous,  and  cold  water  for  the  strong  and  hysterical. 

Gymnastic  exercise,  adapted  to  the  condition  of  each  patient,  is  one 
of  the  most  valuable  means  in  the  management  of  such  cases,  and 
should  come  in  after  strength  has  been  gained  by  massage.  If  there 
is  any  pelvic  disease  which  forbids  the  use  of  the  ordinary  calisthenics, 
the  extremities  should  be  thoroughly  exercised  while  the  patient  is 
reclining.  There  is  no  one  agent  so  potent  in  relieving  chronic  conges- 
tion of  the  internal  organs  as  muscular  exercise.  It  is  equally  efficient 
in  quieting  that  nervous  irritability  which  is  expressed  in  the  hosts  of 
wandering  aches  and  pains  which  torment  this  class  of  patients. 

The  condition  of  a  brain  which  has  for  a  long  time  been  wholly 
occupied  in  looking  after  the  frailties  of  the  body  can  be  greatly 
improved  by  directing  the  will-power  to  the  exercise  of  the  ihuscles. 
I  frequently  see  women  who  because  of  some  uterine  displacement  or 
circumscribed  pelvic  cellulitis  are  directed  to  rest  in  bed  without  any 
mental  or  physical  employment.  Such  imprisonment  is  sufficient  to 
make  an  invalid  of  the  best  kind  of  human  material.  To  keep  an 
army  in  good  condition  requires  constant  occupation  of  both  officers 
and  men,  and  this  rule  applies  to  many  of  our  sick  folks.  Our 
medical  literature  could  well  affbrd  to  have  a  chapter  on  Employ- 
ment for  Invalids. 

After  muscular  exercise,  electricity  comes  in  to  fill  up  time,  and  is 
useful  to  that  extent  at  least.  Patients  who  liave  some  hysterical  ele- 
ments associated  with  these  diseases  of  their  pelvic  organs  are  usually 
most  benefited  by  electricity.  So  says  Rosenthal  in  his  book  on  Dis- 
eases of  the  Nervous  System,  and  my  OAvn  limited  experience  agrees  with 
this.  Some  of  them,  perhaps  many  of  them,  are  feeble  and  require 
medication.  Soothing  medicines  and  nerve-tonics  may  all  be  required, 
and  should  be  employed  while  the  massage,  gymnastics,  and  baths  are 
being  used. 

The  local  treatment  of  the  diseases  of  the  uterus,  the  one  organ  of 
the  sexual  system  which  is  most  amenable  to  local  treatment,  will  be 
fully  discussed  elsewhere.  Some  general  remarks,  however,  on  the 
principal  facts  in  uterine  therapeutics  may  be  permitted  in  this 
connection. 

Local  treatment  of  diseases  of  the  uteiTis  should  be  employed  with 
the  view  of  accomplishing  two  objects :  First,  to  remove  the  disease ; 
and  second,  to  restore  the  organ  to  its  normal  condition.  It  will  at 
once  be  inferred  that  if  the  first  object  is  attained  the  second  will  follow 
as  a  natural  consequence,  but  it  may  or  may  not,  according  to  the  cha- 


GENEUAL  rin:uAPEUTics.  377 

ractcr  ol'  the  (rcatniciit  (.'iii|>Iii\ci|.  1  aiii  .-:ili.-(l<'(|  ili;it  in  timrs  |Ki~t, 
ami  cNcii  at  prt'sciit,  miifli  (»!'  the  trcatiiu'iit  oi"  iitcriiio  disease,  wliile 
it  anvsts  the  iiitiaininatorv  trouhk',  jji'oves  so  destructive  to  the  iionual 
structure  of  the  or<;au  as  to  reuder  the  last  condition  of  the  patient 
■worse  tlian  the  first. 

Disregarding  nuieh  ot"  the;  coul'iising  and  contradictory  literature  on 
the  subject,  I  shall  endeavor  to  fix  attention  upon  a  few  points  which  I 
regard  as  well  established  and  likely  to  be  of  service  in  the  treatment 
of  uterine  disease. 

The  important  questions  which  come  up  for  consideration  on  this 
subject  are — first,  to  what  part  of  the  affected  organs  can  applications 
be  made  ?  second,  what  curative  agents  shall  be  employed  ?  and  third, 
how  shall  they  be  applied  ? 

Turning  to  textbooks  or  the  current  literature  of  the  profession  in 
search  of  an  answer  to  the  first  question,  I  find  the  greatest  diversity 
of  opinions.  The  pioneer  gynecologists  of  Europe,  such  as  M.  Gendrin, 
M.  Jobert  de  Lamballe,  Bennet,  and  Simpson,  rarely  if  ever  made  ap- 
plications beyond  the  os  internum,  believing  that  uterine  inflammation 
could  be  cured  by  treating  the  cervix  and  cervical  canal.  On  the  other 
hand,  we  find  that  Aran,  Scanzoni,  and  Gantillon,  and  in  our  own 
country  Dr.  Henry  Miller  (who,  by  the  way,  was  the  first  to  employ 
intra-uterine  medication  in  this  country),  Kammerer,  Xott,  Peaslee, 
and  many  others,  relied  to  a  very  great  extent  on  intra-uterine  appli- 
cations for  the  relief  of  endometritis  and  uterine  catarrh.  ]\Iany  more 
names  might  be  mentioned  to  show  the  want  of  harmony  among  physi- 
cians on  this  point,  but  no  useful  knowledge  could  be  gained  thereby. 

The  only  point  of  interest  which  we  can  learn  from  this  review  is 
that,  so  far  as  M-e  can  judge,  intra-uterine  medication  is  more  exten- 
sively employed  now  than  formerly.  Believing,  then,  that  time  tends 
to  drift  us  to  the  side  of  correct  therapeutics,  it  may  be  inferred  that 
local  applications  to  a  part  or  to  the  entire  lining  membrane  of  the  ute- 
rine cavity  arc  sometimes  necessary,  if  not  indispensable,  in  treating 
endometritis. 

In  seeking  an  answer  to  the  second  question  we  encounter  a  variety 
of  medicinal  agents,  ranging  from  the  actual  cautery  to  the  blandest 
anodyne  lotion.  Reviewing  the  nature  and  effects  of  the  vari(Uis  reme- 
dies used  in  the  treatment  of  uterine  disease,  we  could  in  no  way  be 
guided  thereby  in  making  a  selection. 

Bearing  in  mind,  however,  the  second  object  to  be  gained — namely, 
to  restore  the  organ  to  health  and  leave  it  uninjured  in  structure — the 
therapeutist  is  bound  at  once  to  reject  all  the  more  ])owcrful  and 
destructive  agents,  such  as  nitric  acid  and  chromic  acid,  caustic  potash, 
and  the  actual  cautery.  All  these  have  been  n-ed,  and  are  now,  though 
less  extensively,   I  trust,  than  formerly,  in  the  treatment   of  simple 


378  GENERAL  THERAPEUTICS. 

chronic  endometritis  or  hypersemia  of  the  mucous  membrane  of  the 
cavity  of  the  uterus. 

Leaving  out  of  account  the  value  of  these  potent  agents  in  the  treat- 
ment of  malignant  diseases  of  the  uterus,  I  desire  to  be  distinctly 
understood  as  opposed  to  their  use  in  the  treatment  of  the  benign  ute- 
rine disease.  I  readily  admit  that  inflammation  of  a  mucous  mem- 
brane can  and  may  have  been  "  cured,"  as  the  expression  is,  by  such 
means.  The  surgeon  can  "  cure "  a  gleet  by  burning  out  the  whole 
mucous  membrane  of  the  urethra  with  caustics.  There  would  be  noth- 
ing left  there  but  a  cicatrix,  which  could  not  secrete  the  glairy  mucous 
discharge  of  gleet ;  but  most  men,  I  am  inclined  to  think,  would  prefer 
the  disease  to  such  treatment  with  such  results.  The  oculist  could 
"cure  "a  chronic  conjunctivitis  in  the  same  way,  but  I  fear  the  eye 
would  be  hardly  presentable  afterward,  and  it  would  surely  fail  to  per- 
form its  function.  Still,  there  are  those  who  treat  the  same  affection  of 
the  mucous  membrane  of  the  uterus  with  these  destructive  agents,  and 
the  results  which  follow  can  be  easily  imagined.  It  may  be  argued,  I 
am  aware,  that  strong  caustics  are  being  used  less  and  less  by  the  pro- 
fession in  the  treatment  of  uterine  disease,  and  I  am  glad  to  believe  that 
such  is  the  case.  The  nitric  and  chromic  acids  and  other  caustics  are 
being  laid  aside,  but  only,  I  fear,  to  give  place  in  some  cases  to  new 
but  none  the  less  destructive  agents:  I  allude  to  galvano-cautery  and 
thermo-cautery.  These  have  become  the  "  fashionable "  caustics  or 
cauteries  of  the  day,  and  I  most  thoroughly  appreciate  their  value  in 
the  treatment  of  malignant  disease  when  the  destruction  of  tissue  is 
called  for.  But  in  the  treatment  of  benign  inflammation  they  cannot 
fail  to  work  a  great  and  uncalled-for  destruction,  like  the  other  agents 
used  in  the  past. 

In  the  management  of  uterine  diseases  one  may  be  guided  by  some 
of  the  generally  accepted  rules  laid  down  by  surgeons  for  the  treatment 
of  inflammation  generally — viz. :  place  the  diseased  organ  at  rest,  quiet 
irritation  by  sedatives,  and  relieve  the  congestion  by  depletion,  astrin- 
gents, alteratives,  and  sedatives.  To  accomplish  these  objects  we  must 
employ  all  the  improved  means  brought  forward  by  modern  investiga- 
tion, changing  and  adapting  them  so  as  to  meet  the  peculiarities  of  each 
case.  First,  then,  secure  rest  by  having  the  patient  abstain  from  long- 
continued  standing  or  walking  and  from  over-excitement  of  the  sexual 
function.  If  the  uterus  is  displaced,  replace  it,  and  sustain  it  in  its 
normal  position  by  the  supjwrt  of  a  M-ell-fitting  pessary  if  need  be. 

To  relieve  pain  and  quiet  the  irritation  a  vaginal  or  rectal  suppository 
made  of  extract  of  belladonna,  one-eighth  to  one-half  grain,  with  cocoa- 
butter,  used  at  bedtime,  will  often  give  great  relief.  Suppositories 
of  iodoform  and  of  conium  are  also  of  service  when  used  in  the  same 
way. 


GENERAL    TIIEUAPEUTICS.  379 

I  desire  to  call  attriitioii  spcrially  to  the  next  ai:;<'iit — iiaiiK-ly,  dcplc- 
tioii — JH'causi'  1  i-('i;anl  it  as  a  remedy  of  some  value.  lii  maUiii^^  tliis 
stiitoinent  I  iiin  aware  tliat  I  eiieoiiiiter  miieli  j(roi'cssi(tiial  |ireju<liee. 
BkHxUettini:;  1i:ls  ceased  t<»  l»e  the  I'asliioii  of  the  day.  The  lancet  is 
comleiniK'd  as  a  "  little  instrument  of  mij^lity  misehief."  Few  of  the 
VountJ-er  menibei-s  of  the  i»r(»fe.ssion  have  ever  si-en  ii  })atient  bled. 
Local  depletion  held  its  own  some  time  after  general  veneseetiou  was  to 
a  great  extent  abandoned,  but  even  this  hits  gradually  given  way  to  the 
popular  prejudii-e  of  the  day.  Nevertheless,  the  fact  in  surgical  thera- 
peutics remains  true  as  ever,  that  the  removal  of  bl(»od  directly  from 
the  vessels  of  an  inflamed  or  congested  organ  gives  some  temporary 
relief. 

Frequent  repetition  of  bloodletting  should  be  avoided,  but  when  a 
case  is  first  seen  in  which  there  is  marked  congestion  the  abstraction  of 
a  little  blood  by  a  few  punctures  around  the  os  externum,  or  the  super- 
ficial scarification  of  the  mucous  membrane  about  the  external  os,  will 
pave  the  way  to  other  applications.  To  practise  depletion  exclasively 
and  persistently,  as  some  of  the  older  gynecologists  did,  is  certainly 
injurious,  but  as  a  means  to  be  employed  in  suitable  cases  it  is  worthy 
of  consideration. 

Hot  water  used  as  a  vaginal  douche  is  an  antiphlogistic  of  much 
value.  It  depletes  the  parts  by  stimulating  the  circulation,  and  is 
M-ithal  something  of  a  local  sedative.  It  is  an  exceedingly  popular 
remedy  at  the  present  time,  and  is  used  rather  indiscriminately  in  all 
diseases  of  the  pelvic  organs  and  with  heroic  persistency.  If  properly 
used,  it  gives  relief  in  congestion  of  the  vagina  and  uterus,  and  in 
cellulitis  when  the  inflammation  is  limited  to  the  cellular  tissue  about 
the  cervix  uteri.  It  is  also  of  service  in  the  passive  congestion  which 
often  accompanies  imperfect  involution,  but  in  pelvic  peritonitis,  salpin- 
gitis, and  ovaritis  it  is  often  harmful. 

The  most  effectual  way  of  using  the  hot-water  douche  is  to  place  the 
patient  on  her  back  over  a  bed-pan  and  use  a  fountain  syringe.  The 
reservoir  should  be  elevated  enough  to  give  the  required  force  to  the 
stream.  The  vaginal  tube  should  be  perforated  on  the  sides  near  the 
end,  but  the  extreme  end  should  be  closed.  This  will  guard  against 
forcing  water  into  the  uterus.  The  temperature  of  the  water  may 
range  from  95°  to  110°  F.,  the  higher  temperature  being  used  only 
when  agreeable  to  the  ]iatient.  The  quantity  to  be  used  may  be  from 
one  to  two  gallons.  "When  too  large  a  quantity  at  a  high  tem]>erature 
is  used  at  the  beginning  of  treatment,  it  sometimes  causes  fiiintness. 
It  is  well,  then,  to  begin  at  a  lower  temperature,  and  gradually  increase 
the  quantity  as  the  patient  gets  used  to  it.  It  is  also  very  liable  to  do 
harm  when  used,  as  it  often  is,  after  plastic  operations  about  the  cer- 
vix uteri  and  perineum. 


380  GENERAL  THERAPEUTICS. 

Another  means  of  depletion  was  introduced  l^y  J.  Marion  Sims.  He 
used  a  small  vaginal  tampon  of  cotton  saturated  with  glycerin,  which 
caused  free  exosmosis  from  the  mucous  membrane,  thereby  relieving 
capillary  engorgement  and  oedema. 

Position  has  much  influence  in  modifying  the  circulation  in  the  pel- 
vis, and  hence  patients  should  avoid  the  too  common  habit  of  sitting 
all  day  in  a  chair  because  tliey  suffer  when  they  w^alk.  Short  periods 
of  walking  or  riding,  followed  by  rest  in  the  recumbent  position,  should 
be  directed. 

When  from  long-continued  congestion  the  mucous  membrane  of  the 
cavity  of  the  uterus  has  become  hypertrophied,  giving  rise  to  that  con- 
dition known  now  as  endometritis  polyposa,  the  use  of  the  curette 
gives  the  most  promjrt  relief.  The  blunt  instrument- should  always  be 
used,  because  it  is  perfectly  effective  and  free  from  danger.  Dilatation 
of  the  cervix  with  tents  as  a  preliminary  to  the  use  of  the  curette  should 
be  avoided.  No  such  dilatation  is  needed,  as  a  rule.  When  the  mucous 
membrane  is  hypertrophied,  the  canal  of  the  cervix  is  usually  suffi- 
ciently dilated  to  admit  a  curette  large  enough  to  do  the  work.  By 
carefully  adhering  to  this  rule  of  practice  the  pain  and  danger  from  the 
use  of  the  tents  are  avoided,  which  are  great  advantages  to  the  patient. 
In  the  great  majority  of  cases  of  corporeal  endometritis  with  thicken- 
ing of  the  mucous  membrane  the  use  of  the  curette  gives  prompt  and 
permanent  relief.  Still,  there  are  some  who  may  require  other  local 
treatment. 

There  is  so  much  risk  in  treating  the  mucous  membrane  of  the  cavity 
of -the  body  of  the  uterus  that  there  are  certain  precautions  which  should 
be  kept  in  mind.  The  principal  rules  for  guidance  may  be  formulated 
as  follows  :  That  intra-uterine  applications  should  not  be  used  until 
other  means  have  been  thoroughly  tried  and  have  failed ;  the  uterus 
should  be  in  or  near  its  normal  position  ;  the  cervix  uteri  should  be 
sufficiently  dilated  to  allow  the  fluid  to  esca])e  from  the  cavity  of  the 
body ;  such  an  instrument  should  be  used  as  will  aid  in  effecting  a  free 
reflux  or  regurgitation. 

After  having  carefully  freed  the  cervical  canal  from  the  secretion, 
the  easiest  and  most  effectual  way  of  making  applications  is  to  use  a 
glass  pipette  Avith  a  small  rubber  bulb  at  one  end,  the  other  end  being 
curved  like  a  uterine  sound.  The  solution  to  be  used  is  drawn  up  into 
the  glass  tube  by  the  rubber  bulb ;  the  instrument  is  then  passed  up  to 
the  OS  internum  or  to  the  fundus  uteri  if  desired,  and  as  it  is  withdrawn 
pressure  upon  the  bulb  forces  out  tlie  solution  and  brings  it  in  contact 
wnth  the  entire  lining  of  the  canal.  The  method  generally  in  use,  of 
dip])ing  a  probe  wrapped  in  cotton  into  the  solution,  and  passing  that 
up  into  the  canal,  is  very  unsatisfactory.  The  cotton  on  the  probe 
injures  the  mucous  membrane,  and  tlie  solution  is  deposited  about  the 


G  EX  Ell  A  L    TilKllM'KrTirS.  381 

OS  extcniuiu,  very  little  if  any  j^ettiii;;  iij)  into  the  canal.  '\\iv  injection 
or  instillation  >lioulil  l>e  made  very  slowly,  IjeeaiLse  the  uterus  will  not 
tolerate  distension. 

The  hiandest  Hiiid  on;:;ht  to  be  tried  first,  in  order  to  te-t  the  toler- 
ance of  the  uterus;  a  little  warm  water  with  tahle-salt  1  have  found 
agreeahle;  perhaps  cocaine  would  be  the  l>est ;  and  no  a;^ent  whatever 
should  be  used  which  mitrht  jx-rmanently  injure  the  nnicous  membrane. 

In  most  cases  the  canal  of  the  cervix  is  sulHcienily  ojmmi  to  permit 
intra-uterine  applications,  but  it  may  be  neces.sary  to  pnxiuce  dilatation 
as  a  pn-liminarv  stej).  \\  hen  such  is  the  ease  the  u<ii  of  the  uterine 
dilator  will  answer. 

The  treatment  of  the  cervical  canal  is  fortunately  simpler,  being 
more  easv  to  reach  and  nuicli  more  tolerant  of  irritation.  The  only 
ditHculty  in  the  way  of  making  ai)plications  is  the  tenacious  secretion 
which  tills  the  canal.  This  should  be  removetl  with  a  small  curette 
before  makinir  the  a])plication. 

Regarding  the  agents  to  be  used  in  cervix  or  body  a  long  list  might 
be  given.  It  will  suffice  to  say  that  the  safest  and  most  efficient  are 
mild  solutions  of  sulphate  of  zinc,  chloride  of  zinc,  nitrate  of  silver, 
tiimiie  acid,  tincture  of  iodine,  and  carbolic  acid,  my  own  preference 
for  general  use  being  tincture  of  iodine  two  parts  and  carbolic  acid 
one  part.  The  fref{ue'.icy  with  which  these  local  aj)plications  should 
be  ma<le  depends  upon  the  nature  of  the  lesions.  In  oi'dinarv  cervical 
and  corporeal  endometritis  ouce  every  five  or  six  days  will  suffice.  This 
gives  time  for  the  tissues  to  fully  profit  by  the  application  made  before 
it  is  repeated. 

I  am  aware  that  the  practice  with  some  is  to  make  local  applications 
every  day  or  every  other  day,  but  I  know  that  this  constant  manipulat- 
ing is  irritatiny;  and  does  more  harm  than  Q-ood. 

Cocaine,  the  therapeutical  action  of  which  has  recentlv  been  discov- 
eretl,  is  a  most  valuable  addition  to  the  materia  niedica.  The  irvnecol- 
ogist  hfis  long  felt  the  need  of  some  agent  that  would,  when  applied 
locally,  act  as  an  anaesthetic,  and  cocaine  has  largely  supplied  the  much- 
needed  agent.  Its  chief  value  is  in  rendering  the  parts  to  which  it  is 
applietl  less  sensitive  during  the  application  of  curative  agents  which 
are  necessarily  painful.  Cocaine  lessens  the  blood-supply  in  the  jiarts 
to  which  it  is  applied,  at  the  same  time  that  it  benuml)s  them,  and  on 
that  account  it  was  hoped  that  cocaine  would  be  a  valuable  remedy  in 
inflammatory  aifections.  It  appears,  however,  that  its  effects  are  very 
temporary,  and  it  remains  to  be  seen  how  efficacious  it  may  be  in  this 
respect. 

It  has  also  been  used  as  a  local  anaesthetic  while  ])erforming  plastic 
operations  ujion  the  pelvic  organs.  In  this  it  has  ])rovc(l  to  be  too  su- 
perficial in  its  action  to  control  the  pain  caused  by  wounding  the  deeper 


382  GENERAL  THERAPEUTICS. 

nerves.  Perhaps  by  using  it  hypodermically  or  applying  it  to  the 
exposed  parts  as  the  operation  progresses  it  may  prove  of  yet  greater 
capabilities.  So  far,  I  have  found  it  very  useful  in  relieving  tenderness 
of  the  vulva,  which  makes  examinations  of  the  pelvic  organs  by  toucli 
and  speculum  otherwise  impossible. 

It  also  relieves  the  painful  urination  of  urethritis,  and  also  the  pain 
caused  by  injections  in  this  affection  if  used  frequently.  It  also 
benumbs  the  mucous  membrane  of  the  cervical  canal,  so  that  the  ute- 
rine sound  or  dilator  can  be  used  in  sensitive  cases  without  the  usual 
pain.  Possibly,  it  may  relieve  the  sensitiveness  of  the  corporeal  mucous 
membrane,  thereby  rendering  intra-uterine  medication  less  painful  and 
dangerous.     But  this  has  yet  to  be  demonstrated. 

To  carry  out  a  systematic  course  of  treatment,  such  as  has  been 
briefly  referred  to  here,  is  difficult  in  general  practice.  Granting  that 
one  has  the  requisite  medical  and  surgical  knowledge,  it  is  difficult  to 
obtain  the  means  necessary.  In  private  life  proper  nursing  is  hard  to 
obtain.  There  are  few  who  can  afford  a  well-trained  nurse  for  any 
length  of  time,  and  if  that  obstacle  be  overcome  the  constant  interfe- 
rence of  relatives  and  friends  thwarts  the  effbrts  of  both  physician  and 
nurse  to  obtain  and  keep  complete  control  of  the  patient.  This  throws 
extra  care  upon  the  physician  or  surgeon,  and  limits  the  number  of 
cases  that  one  can  take  charge  of.  In  view  of  these  facts  it  may  be 
concluded  that  one  can  treat  a  larger  number  of  cases  in  an  institution 
especially  arranged  for  that  purpose  with  more  ease  and  satisfaction  than 
in  private  practice. 


ELECTRICITY  IN  GYNECOLOGY. 

Br  A.   D.  ROCKWELL,   A.M.,  M.  D., 
Nkw  York. 


While  electricity  as  a  therapeutic  agent  uiuloubtedly  finds  its  widest 
field  in  neurologicid  eases,  yet  it  is  by  no  nieane  to  be  restricted  to  the.se 
contlitions.  In  every  special  department  of  medicine  it  nmst  at  times 
enter  as  an  important  factor,  and  those  who  would  keep  abreast  the 
current  must  reci)gnize  this  fact.  ()[)hthaliuolo<iy,  laryngology,  derm- 
atoh)gy,  even  obstetrics,  own  its  value,  but  it  is  in  the  treatment  of 
certain  gynecological  cases  that  its  greatest  efficacy  lies.  I  have  for 
yeare  held  that  it  should  occupy  a  far  higher  place  in  the  armamenta- 
rium of  the  gynecologist  than  it  has  yet  occupied,  but  until  experts  in 
this  department  give  the  subject  their  personal  attention  by  making 
themselves  familiar  w'ith  the  physics  and  physiology  of  electricity  and 
the  dilfereutial  indications  for  its  use,  and  finally  supplement  theoretical 
knowledge  by  clinical  experience,  the  popularization  of  this  invaluable 
remedy  for  the  relief  of  the  disea.ses  of  women  will  be  slow. 

Almost  every  disease  peculiar  to  women  has  been  treated  by  electri- 
city, and  if  the  many  remarkable  results  recorded  could  be  accepted  as 
typical  of  the  ordinary  effects  of  electrization,  it  might  be  considered 
almost  a  panacea  for  this  class  of  cases. 

While  disorders  of  menstruation,  engorgements,  flexions,  prolapsus, 
atrophy,  etc.  have  all  been  treated  with  more  or  less  success,  it  should 
always  be  borne  in  mind  that  in  the  majority  of  the  diseases  peculiar 
to  women  this  success  has  followed  when  the  electrical  has  supple- 
mented, and  not  superseded,  other  and  more  thoroughly  approved 
methods  of  treatment.  In  estimating  the  value  of  electricity  not 
only  in  gynecology  but  in  every  other  class  of  disease,  it  is  essential 
that  its  general  therapeutical  action  be  properly  appreciated.  The 
old  idea  that  it  was  merely  a  stimulant,  useful  to  prick  up  paralyzed 
muscles,  limited  its  application  for  many  years  to  the  various  forms 
of  paralysis. 

The  acceptance  of  the  view  that  electricity  is  a  tonic,  and  a''  .such  has 
a  powei'ful  influence  over  nutrition,  has  wrought  a  revolution  in  electro- 
therapeutics, and  readily  accounts  for  its  value  in  such  a  wide  variety 
of  disea.ses. 

But  not  only  is  electricity  a  stimulant  and  a  tonic,  but  under  certain 

383 


384  ELECTRICITY  IN  GYNECOLOGY. 

conditions  it  acts  as  one  of  our  most  efficacious  sedatives,  and,  paradox- 
ical as  the  term  "stimulating  sedative  tonic"  may  at  first  appear,  all 
experience  is  in  favor  of  this  term  as  expressive  of  its  place  in 
medicine. 

The  stimulating  effects  of  electricity  are  in  reality  far  less  important 
than  those  of  sedation  and  improvement  in  nutrition,  and  only  because 
its  power  of  stimulation  was  formerly  regarded  as  almost  the  exclusive 
test  for  the  use  of  electricity  in  medicine  can  we  account  for  its  slight 
progress  in  professional  popularity  through  so  many  years.  AVe  now 
know  that  it  relieves  many  forms  of  pain,  gives  tone  to  the  system, 
and  frequently  improves  nutrition  after  ordinary  tonics  and  sedatives 
have  failed. 

As  in  many  of  the  diseases  peculiar  to  women  it  is  of  prime  import- 
ance to  improve  both  the  local  and  the  general  nutrition,  and  to  pro- 
duce not  only  stimulating  but  sedative  effects,  it  is  quite  iu  order  here 
to  say  a  few  words  iu  regard  to  the  methods  by  which  these  results 
can  be  obtained. 

General  Faradization. 

Electricity  is  no  exception  to  the  general  law  that  in  order  to  obtain 
the  constitutional  tonic  effects  of  a  remedy  the  whole  system  must  be 
brought  under  its  influence.  It  is  not  a  whit  more  irrational  to  expect 
one  to  appreciate  the  full  tonic  effects  of  cold  water  by  washing  one  arm 
only  than  it  is  to  expect  the  full  effects  of  electricity  by  using  it  locally. 
Experience  here  confirms  analogy,  and  teaches  that  the  constitutional 
tonic  effects  of  electricity  can  only  be  obtained  by  making  the  applica- 
tions all  over  the  person  and  to  the  central  nervous  system.  The 
results  of  these  methods  are  variously  modified  according  to  the  con- 
ditions of  disease  or  special  idiosyncrasies  of  the  patient. 

It  may  be  here  remarked,  also,  that  there  is  no  remedy  to  the  effects 
of  which  there  is  a  more  varying  degree  of  susceptibility.  Some 
patients,  for  example — and  perhaps  the  majority— experience  a  feeling 
of  enlivenment  and  exhilaration  after  a  judiciously-directed  general 
application.  In  others  the  tendency  may  be  to  sleep,  and  in  such 
cases  the  patient  should  be  permitted,  and  even  enjoined,  to  quietly 
repose  for  some  time  after.  Because  of  this  disposition  to  sleep  which 
is  so  often  observed,  it  becomes  in  many  cases  desirable,  especially  when 
insomnia  is  present,  to  administer  the  applications  at  night  before  retir- 
ing. The  relief  from  indefinable  nervous  pains  and  from  general  and 
local  weariness  is  a  very  agreeable  and  not  infrequent  temporary  effect 
of  general  faradization.  Sometimes  this  feeling  of  relief  lasts  for  sev- 
eral hours,  and  at  other  times  for  a  much  shorter  period,  but  in  either 
case  persistent  efforts  will,  as  a  rule,  result  iu  more  or  less  permanent 
benefit. 


LOr.l  L TZF.D   FL FXTH IZ. I  TION.  385 

The  most  thoroii;;!!  form  of  «z;tMR'ral  furadi/.atioii  dcmaiids  tliat  tljc 
Avliolo  surface  of  the  body,  from  the  erowii  of  tin;  head  to  the  soles  of 
tlie  feet,  shall  he  suecossivolv  hronjrht  under  th<;  iulluence  of  the  faradic 
current.  Vov  this  |)ur|)()S('  the  feet  of  the  jwtient  may  he  placed  upon 
a  broad  ])iece  of  copper,  to  which  the;  nei^ativo  })i>le  is  attached,  while 
the  positive  (either  the  moistened  hand  of  the  ojjerator  or  a  line  and 
soft  sj)oni;"e  enclosing  a  metal  ball)  is  applied  to  the  various  porticjns 
of  the  body.  To  successfully  utilize  j»;eneral  faradization  requires  some 
mechanical  dexterity,  entire  familiarity  with  the  instruments  required, 
a  complete  knowleduje  of  electro-therapeutical  anatomy,  and  a  personal 
acquaintance  with  the  sensations  and  behavior  of  all  portions  of  the 
body  under  tlie  different  electric  currents.  The  true  method  of  learn- 
ing the  art  of  general  faradization  is  by  repeated  observations  of  its  ap- 
plication to  the  living  subject,  by  personal  experience  of  its  sensati<jns 
and  results  at  the  hands  of  practised  adepts,  and  by  careful  experinieiit- 
ing  ou  diverse  temperaments  and  in  opposite  states  of  disease.^ 


Localized  Electrization. 

As  the  term  sufficiently  indicates,  localized  electrization  is  supposed 
to  affect  but  a  comparatively  limited  portion  of  the  body,  and  its  effects, 
primary,  secondary,  and  permanent,  are  not  at  all  such  as  those  that 
have  just  been  considered. 

The  object  of  localized  electrization  is  to  confine  the  direct  action  of 
the  ciu'rent,  so  far  as  possible,  to  some  particular  part  of  the  body. 
This  is  accomplished  by  placing  electrodes  so  that  the  current  in  pass- 
ing from  one  to  the  other  shall  chiefly  traverse  the  special  part  to  be 
affected.  When  the  current  is  localized  by  means  of  moistened  elec- 
trodes, it  diffuses  itself  through  the  body  between  the  electrodes  in 
various  directions.  The  extent  of  this  diffusion  will  be  variously 
modified  by  the  relative  position  of  the  electrodes  and  the  structure 
and  relation  of  the  parts  that  lie  between  them.  It  is  manifest  also 
that  the  effects  of  the  current  will  be  greatest  near  the  electrodes  and 
least  at  the  farthest  point  l)etween  them.  The  strength  of  the  current 
being  the  same,  small  electrodes  are  more  painful  than  those  with  a 
broad  surface,  and  metallic  more  than  wet  sponge  or  flannel.  The  least 
painful  form  of  artificial  electrode  is  a  soft  sponge  with  a  broad  surface 
and  well  moistened,  or,  better  still,  one  of  absorbent  cotton  covered  with 
chamois-skin. 

Localized  electrization  has  to  a  limited  extent  the  same  direct  effect 
on  the  part  to  which  the  ap]ilication  is  made  that  general  electrization 
has  on  the  Avhole  bodv.     The  leadino;  and   (general  effect  of  localized 

^  For  fuller  details  of  tliis  method  the  reader  is  referred  to  Beard  and  Euckwell's 
Practical  Treatise  oh  Medical  and  Surc/icat  Electricity. 
Vol.  I.— 25 


386  ELECTRICITY  IN  GYNECOLOGY. 

electrization,  and  one  Avhich  is  a  complex  result  of  the  various  special 
effects,  is  inaprovement  in  nutrition.  Localized  electrization  of  an  atro- 
phied or  poorly-nourished  muscle  causes  that  muscle  to  improve  in  size 
and  strength ;  localized  electrization  of  an  atrophied  or  poorly-nour- 
ished organ,  as  the  uterus,  causes  it  to  increase  in  size  and  improve  in 
functional  activity.  When  the  nutrition  of  an  atrophied  part  is  im- 
proved, it  grows  larger;  when  the  nutrition  of  an  hypertrophied  part 
is  improved,  it  grows  smaller.  In  both  atrophy  and  subinvolution  of 
the  uterus  I  have  iu  various  instances  verified  this  statement. 

The  local  treatment  of  the  uterus  and  its  appendages  may  be  either 
external  or  internal.  The  external  treatment  consists  simply  in  placing 
one  pole  in  front  over  some  portion  of  the  abdomen,  according  to  the 
indications  of  the  case,  and  the  other  over  the  lower  lumbar  region. 
This  method  is  frequently  of  essential  service  in  the  disorders  of  men- 
struation and  in  ovarian  pain,  and  iu  the  case  of  virgins  should  cer- 
tainly be  attempted  before  resorting  to  the  internal  method.  The  local- 
ization of  the  current  in  the  uterine  organs  is  in  this  way  of  course  only 
partial,  and  far  less  effective  tlian  internal  applications,  and  the  benefit 
derived  is  undoubtedly  in  part  due  to  the  effects  of  the  current  on  the 
lower  part  of  the  spinal  cord  and  the  abdominal  ganglia  of  the  sym- 
pathetic. 

The  internal  treatment  of  the  uterus  and  ovaries  may  be  effected  in 
several  ways.  Usually,  the  introduction  of  one  pole  is  sufficient,  the 
other  being  applied  externally  either  at  the  nape  of  the  neck  near  the 
sixth  cervical  vertebra,  over  the  lumbar  region,  or,  as  is  most  generally 
the  case,  on  the  abdomen,  according  to  the  special  indications  of  the 
case  in  hand. 

The  internal  electrode  may  be  applied  either  to  the  cervix  uteri,  to 
the  interior  of  the  uterus,  or  in  the  rectum.  In  the  treatment  of  dis- 
placements it  has  been  customary  to  apply  both  poles  internally,  one  to 
the  uterus  and  the  cither  in  the  rectum  or  bladder,  according  to  the 
character  of  the  flexion.  Applications  to  the  cervix  are  made  by  lueans 
of  an  insulated  electrode  with  a  metallic  bulb,  or,  instead  of  the  bulb, 
small  plates  may  be  used  to  clasp  the  os.  Excepting  where  cauterizing 
effects  are  desired,  the  internal  electrode  should  be  covered  with  cham- 
ois, soft  sponge,  or  absorbent  cotton.  An  ordinary  Sims  sound,  if 
insulated  to  within  about  an  inch  of  the  extremity,  answers  very  well 
for  an  intra-uterine  electrode. 

The  vagina  may  be  treated  by  a  straight  or  slightly  curved  metal 
electrode — a  method  which  may  sometimes  prove  useful  in  the  treat- 
ment of  leucorrhoea  and  prolapsu.s.'  When  we  desire  in  these  local 
applications  the  mechanical  rather  than  the  chemical  effects  of  elec- 

^  These  various  electrodes  ■will  be  found  illustrated  in  the  catalogues  of  most  instru- 
ment manufacturers. 


LOf'AT.TZF.J)   KLKfTUIZATlnS.  3g7 

tricity,  as  is  tlie  case  in  the  troatiiiciit  of  (lisplacouiciits,  tin-  Caradif  mr- 
rt'nt  is  to  l)('  prct'crrcd  to  the  ^ilvaiiic 

It  is  an  interesting  and  important  I'act  to  he  lioriic  in  niin<l  that 
internal  are  relatively  far  less  j)ainful  than  external  application^.  \'ery 
many,  therefore,  in  Hi-st  attemptinji;  this  method  of  treatment  are  sur- 
prised that  the  sensiitions  under  the  broad  surface  of  the  external  elec- 
trode are  comj)lained  of  more  than  those  at  the  point  of  contact  of  the 
small  internal  electrode.  It  may  he  here  stated,  in  general,  that  the 
negative  pole  is  far  more  frequently  indicated  for  internal  apj)lications 
than  the  positive.  More  specific  statements  will  he  made  when  cnii>id- 
ering  individual  diseases. 

SniKNGTH  OF  Current. — In  the  use  of  electricity  in  gynecology, 
as  well  as  in  other  forms  of  disease,  it  is  essential  that  the  strength  of 
the  current  be  always  known  to  the  operator.  The  variation  of  the 
strength  of  the  faradic  current  cannot  be  so  readily  appreciated  bv  anv 
instrument  of  precision  as  can  that  of  the  galvanic  current,  and  fortu- 
nately the  same  necessity  does  not  exist.  The  strength  of  the  former 
can  always  be  approximately  estimated  by  the  appliances  attached  to 
the  apparatus. 

For  the  intelligent  use  of  galvanism,  however,  a  galvanometer, 
registered  in  milliamperes,  is  of  the  first  importance,  and  no  one  can 
hope  to  perform  satisfactory  work  without  it.  There  can  be  no  question 
but  that  too  weak  currents  have  hitherto  been  used  in  the  treatment  of 
many  diseases  of  the  female  sexual  apparatus.  Various  conditions 
which  I  formerly  failed  to  relieve  have  of  late  years  responded  far 
more  readily  to  treatment,  simply  because  of  the  greater  intensitv  of 
current  that  I  have,  with  increased  boldness,  attempted.  Opinions 
may  differ  in  regard  to  the  number  of  milliamperes  necessary  to 
accomplish  a  given  object.  Some  observers,  and  notably  Apostoli  in 
France,  make  use  of  most  powerful  currents;  in  the  treatment  of  uterine 
fibroids  and  hyperplasia  uteri  especially  his  milliamperes  often  register- 
ing considerably  above  a  hundred,  and  Engelmann  claims  to  have  gone 
as  high  as  two  hundred  and  fifty.  Excepting  for  electrolytic  jiurposes, 
however,  it  is  rarely  necessary  to  use  a  strength  of  more  than  fifty  milli- 
amperes. 

The  covering  of  the  metal  electrode  is  not  of  prime  importance,  so 
long  as  the  proper  strength  of  current  is  attained.  This  much  may, 
however,  be  said  in  regard  to  electrodes  :  they  var\'  decidedly  as  to 
their  conductibility.  The  ordinary  sponge  electrode  is  necessarily 
bulky,  offering  a  greater  resistance  to  the  passage  of  the  current  than 
some  others.  A  large  amount  of  electrical  force  is  therefore  lost.  This 
loss  cannot  be  afforded,  especially  when  the  phvsician,  as  is  generally 
the  case,  has  but  a  limited  number  of  cells  at  command.  Far  better 
than  sponge,  in  that  it  conducts  more  readily  and  can  be  changed  for 


388  ELECTRICITY  IN  GYNECOLOGY. 

every  patient  with  little  expense,  is  the  ordinary  absorbent  cotton.  A 
thin  layer  is  spread  over  a  flexible  metal  plate  with  a  covering  of 
chamois. 

The  size  of  the  external  electrode  is  determined  by  the  strength  of 
the  current.  It  should  vary  in  diameter  from  two  to  six  inches  or  more, 
according  as  the  current  varies  from  five  to  fifty  milliamperes  in  strength. 
Such  details,  however,  each  worker  will  readily  discover  for  himself. 
Individuals  are  so  differently  susceptible  in  this  respect  that  no  state- 
ment in  regard  to  size  of  electrode  is  applicable  to  all.  A  statement 
that  has  been  already  made  I  here  repeat :  It  should  never  be  forgotten 
that  the  female  generative  organs  are  not  at  all  sensitive  to  electrical 
applications,  whether  galvanic  or  faradic.  The  most  excessive  pain 
may  be  occasioned  and  decided  escharotic  effects  follow  where  the 
electrode  is  applied  to  the  skin,  while  absolutely  no  sensation  has  been 
experienced  at  the  point  of  contact  of  the  internal  electrode.  The  inter- 
nal electrode  will  cause  little  or  no  pain  even  when  a  strength  of  fifty 
and  even  more  milliamperes  is  used,  and  the  only  way  to  obviate  the 
acute  burning  at  the  external  electrode  is  to  have  it  very  large,  covering 
even  the  whole  abdomen  if  necessary.  For  this  purpose  Apostoli  uses 
a  layer  of  clay  over  the  abdomen.  This,  however,  is  not  necessary,  as 
a  well-covered  plate,  say  of  heavy  tin-foil,  kept  in  place  and  closely 
applied  to  the  skin  by  a  sand-bag,  will  do  equally  well. 

Disorders  of  Menstruation. 

Amenorrhsea,  dysmenorrhoea,  and  menorrhagia  are  the  symptoms  for 
the  relief  of  which  electricity  in  some  form  is  very  frequently  indi- 
cated, but  the  measure  of  success  to  be  obtained  by  this  as  by  all  other 
methods  must  depend  upon  the  causes  or  special  character  of  the  symp- 
toms. It  is  often  asserted  that  electrization  acts  most  capriciously  in 
these  affections,  but  to  all  who  are  conversant  with  uterine  pathology 
these  inconsistent  results  are  entirely  explicable.  Cases  that  are  in- 
discriminately treated  must  frequently  result  in  a  manner  very  disap- 
pointing. 

In  offering  a  favorable  prognosis  in  a  given  case  of  suppressed  men- 
struation it  is  assumed  that  no  serious  local  pathological  condition  exists. 
In  cases  associated  with,  and  more  or  less  dependent  upon,  chlorosis  or 
nervous  exhaustion  the  important  thing  is  not  to  specially  stimulate  the 
uterus,  but  to  change  the  constitutional  condition  which  is  the  cause  of 
the  suppression  of  the  function.  Accordingly,  the  treatment  by  general 
faradization,  combined  with  such  internal  medication  as  may  be  spe- 
cially called  for,  is  generally  sufficient  without  applications  directly  to 
the  uterus.  Indeed,  the  majority  of  cases  of  functional  disease  of  the 
uterine  organs  require  general  as  well  as  localized  electrization.     There 


j)is()i:i)i:i:s  of  Mhwsr/n'ATiox.  389 

is  IK)  (Icpai'tmciit  in  wliidi  iiu»ic  inistaUcs  have  hccn  made  hv  too  cxclii- 
sivc'ly  local  I'lictrical  trratiiu-iit  than  in  j;ynfcolo;ry.  2S'o  case  of  I'iuk;- 
tional  tli.stnil)an(('  of  tlic  nicins  >lionl(l  he  ahaiidoned  until  {xciicral  uh 
well  as  oxti'rnal  and  internal  loc;di/('d  electrization  has  heen  tried.  Oik; 
of  the  stron<;-est  evidences  of  the  heuelicial  residls  to  he  ohtained  hy 
general  fara«lizatioii  in  cases  of  anienorrhu3a  lies  in  the  fre(|iiently 
ohserved  fart  that,  when  treated  for  other  conditions,  patients  not 
infrecjucntly  speak  of  some  chanjie  in  the  character  of  the  menses.  Jn 
some  cases  they  are  brought  on  before  their  time — in  others,  much 
increased   in  (juantity. 

In  addition  to  methods  of  application  there  are  several  other  })oints 
to  be  considered.  The  time  of  making  the  applications  is  not  unim- 
portant. It  is  an  advanta;j;e,  in  amenorrlKoa  at  least,  to  concentrate  a.s 
many  aj)j)lications  as  possible  during  the  few  days  that  i)recede  the  time 
for  the  api)earance  of  the  menses.  And  yet,  as  the  great  thing  in  all 
but  recent  and  temporary  cases  is  to  remove  the  chlorosis  or  nervous 
exhaustion  with  which  the  menstrual  disorder  is  associated,  and  of 
which  it  is  a  prominent  factor,  the  advantage  of  this  is  hardly  as  great 
as  has  been  supposed  by  some.  AVhatever  method  is  used,  time  is  also 
necessary  to  ensui'e  results.  While  it  is  true  that  a  single  application, 
especially  internal,  may  bring  on  the  menses — may  even  cause  the  blood 
to  appear  during  the  sitting — ^yet  in  the  majority  of  instances  treatment 
must  be  more  or  less  protracted  in  order  to  ensure  permanent  relief. 

The  kind  of  electricity  to  be  used  is  also  a  question  of  prime  import- 
ance in  the  treatment  of  amenorrhea.  All  three  forms,  galvanic, 
faradic,  and  franklinic,  have  been  used  successfully,  and  not  infrequently 
M'hen  one  kind  fails  after  repeated  efforts  another  succeeds.  Experience 
has  not,  however,  altogether  failed  to  afford  some  data  for  the  best 
methods  of  procedure.  In  any  case  of  amenorrhcea  where  the  patient 
is  weak  and  ansemic,  with  other  and  well  understood  evidences  of  mal- 
nutrition, the  faradic  current  is  strongly  indicated  over  the  galvanic. 
As  already  stated,  the  applications  should  be  general,  althoutrh  the 
local  treatment,  when  permissible,  is  always  in  order  and  undoubtedlv 
hastens  the  effects  desired.  Localized  galvanization  is,  as  a  rule,  not 
only  not  indicated,  but  in  many  cases,  as  I  have  had  abundant  occasion 
to  observe,  tends  to  induce  a  condition  of  nervous  irritation  that  is 
exceedingly  unpleasant.  It  is  only  as  regards  the  local  application  that 
this  objection  to  the  use  of  galvanism  holds  in  these  cases.  Central 
galvanization  may  very  effectually  supplement  the  action  of  general 
faradization  in  the  hysterically  inclined  and  the  sleepless,  calming  fre- 
quently in  a  wonderful  degree  and  producing  refi-eshing  slumber.  If, 
on  the  contraiy,  the  patient  is  robust  and  of  a  fidl  habit,  galvanism  is 
likely  to  be  of  far  greater  service  than  either  faradism  or  franklinism. 

The  applications  should  by  preference  be  local  and  internal,  although 


390  ELECTRICITY  IN  GYNECOLOGY. 

external  treatment  alone  may  in  many  cases  be  sufficient.  As  it  is 
often  desirable  that  mechanical  effects  be  produced,  it  is  frequently  of 
service  to  rapidly  interrupt  the  current,  taking  care  to  avoid  too  pow- 
erful contractions  of  the  external  muscles,  I  have  frequently  known 
menstruation  to  follow  the  use  of  franklinic  electricity,  but  a  consid- 
erable experience  has  convinced  me  that  it  is  for  this  purpose  not  only 
inferior  to  dynamic  electricity,  but  in  the  long  run  is  equal  to  neither 
of  its  two  forms,  galvanism  and  faradism.  For  some  unexplainable 
reason,  however,  it  does  in  this  disease  as  in  several  others  sometimes 
act  when  dynamic  electricity  has  failed,  illustrating  the  limitations  of 
our  knowledge  of  the  differential  indications  for  the  use  of  the  differ- 
ent forms  of  electricity.  In  regard  to  the  choice  of  poles,  it  makes 
little  if  any  difference  when  the  faradic  current  is  used  which  is 
selected.  In  the  use  of  galvanism,  however,  I  most  decidedly  prefer 
the  positive  pole  as  the  internal.  Its  superiority  over  the  negative  pole 
for  the  relief  of  this  symptom  depends  most  probably  upon  its  greater 
influence  over  unstriped  muscular  fibre. 

Dysmenorrhcea. — The  very  satisfactory  results  that  frequently 
follow  the  applications  of  electricity  in  dysmenorrhcea  will  not'  be 
denied  by  those  who  have  had  any  adequate  experience  in  its  use. 
Either  of  the  three  forms  of  electricity  may  be  of  service,  but,  as  a  rule, 
the  galvanic  current  is  far  more  effective  in  affording  relief  than  either 
faradism  or  franklinism.  It  is  in  the  so-called  neuralgic  dysmenor- 
rhcea and  that  due  to  spasm  of  the  os  uteri  that  galvanism  is  more 
especially  called  for.  External  applications  alone  are  sometimes  suf- 
ficient, but  if  these  fail  the  case  should  not  be  abandoned  until  the 
internal  method  is  faithfully  tried. 

In  many  cases  great  relief  will  follow  applications  to  the  cervix  uteri 
after  persistent  external  treatment  has  failed.  To  those  who  understand 
the  physical  and  chemical  effects  of  galvanism  it  would  seem  hardly 
necessary  to  say  a  word  against  the  use  of  anything  but  a  steady  con- 
tinuous current,  yet  instances  not  a  few  have  come  under  my  observa- 
tion where  practitioners  have  failed  to  C!onsider  this  simple  point,  and 
have  thus  occasionally  aggravated  the  symptoms  for  which  relief  has 
been  sought.  In  most  cases  of  ordinary  dysmenorrhcea,  whether  treated 
externally  or  internally,  my  method  is  to  gradually  increase  the  strength 
of  the  current  without  interruptions. 

The  strength  Avill  depend  altogether  upon  the  character  of  the  case 
in  hand.  Some  will  bear,  and  be  benefited  by,  a  current  of  thirty 
milliamperes  and  more,  while  others  wouJd  receive  injury  rather 
than  benefit  from  such  strong  currents.  Let  the  first  application 
be  tentative,  and  the  strength  best  suited  to  the  case  will  soon  be 
found.  When  prolonged  and  strong  applications  are  necessary,  the 
ordinary  uterine  electrode  applied  directly  against  the  tissues  is  some- 


DISORDERS  OF  MESSTRVATIOy.  .•>91 

times  followed  hy  iukIik'  local  ii'ritatioii.  'J\»  avoid  this  the  f'ollowiiif^ 
ineth(Kl  eati  Ije  lollowed  to  advautaj^c :  Soft  and  line  sprtji^ros  may  he 
ciiref'ully  packed  around  the  cervix,  pressing  up  against  the  ImxIv  ol'the 
uterus.  Against  these  is  gently  hut  firmly  pressed  a  flat  nu-tallie  elec- 
trode covered  with  wet  ehamois-skin.  Jiy  interralating  a  rheostat,  and 
heginning  with  the  least  possible  current-strength,  the  nundjer  of  cells 
that  mav  gradu:dly  and  without  discomfort  be  brought  int(»  the  circuit 
far  exceeds  the  mnnber  that  could  be  used  without  this  preraution.  It 
will  be  readily  understoinl  that  in  gradually  increasing  the  current  in 
this  way  it  is  as  important  to  as  gradually  decrease  it  before  removing 
the  electrodes. 

In  amenorrhcea,  either  pole,  when  applied  to  the  uterus,  may  be  fol- 
lowed by  the  best  of  results.  The  negative  in  the  subjective  sensations 
that  it  causes  is  the  stronger,  but  the  positive  Ls  decidedly  preferable 
in  some  cases,  because  its  tendency  is  to  more  readily  contract  the 
involuntary  muscidar  fibres.  In  the  treatment  of  neuralgic  dysmen- 
orrhcea,  also,  the  positive  pole  locally  applied  is  undoubtedly  prefer- 
able. On  physiological  grounds  alone  this  conclusion  might  readily 
enough  be  reached,  but,  unfortunately,  electro-physiology  is  as  yet  but 
a  very  uncertain  guide  in  many  casas.  I  have  therefore  for  years  care- 
fully observed,  and  as  carefully  recorded,  the  differential  effects  of  the 
poles  in  this  condition,  and  have  become  convinced  that  the  average 
results  are  superior  when  the  positive  pole  is  used.  When,  however, 
dysmenorrhcea  is  due  to  mechanical  causes  that  are  well  defined,  when 
the  nerve-filaments  are  pressed  upon  by  exudations,  when  the  canal 
is  occluded  by  chronic  inflammatory  swellings, — the  negative  pole  is 
alwavs  to  be  used. 

Menorrhagia. — In  the  electrical  treatment  of  menorrha^ia  the 
results  are  not  so  frequently  efScacious,  by  any  means,  as  in  the  forms 
of  disordered  menstruation  just  considered.  In  very  many  cases  its 
origin  is  such  that  electricity  can  prove  of  but  little  if  any  value,  while 
there  arc  other  cases  where  the  benefit  to  be  derived  cannot  be  over- 
estimated. On  the  same  principle  that  we  use  general  fm-adization  in 
cases  of  amenorrhcea  associated  with,  and  perhaps  dependent  upon,  a 
weak  chlorotic  condition  of  system,  we  make  applications  of  it  where 
similar  symptoms  are  associated  in  the  menorrhagic  subject.  In  not  a 
few  such  cases  I  have  known  simple  external  treatment  by  this  method 
to  be  followed  by  comj^lete  and  permanent  cessation  of  the  excessive 
flow  and  a  corresponding  improvement  in  appearance  and  strength. 
In  menorrhagia  due  to  such  local  causes  as  misplacements,  intra-uterine 
morbid  growths,  certain  affections  of  the  ovaries,  etc.  ordinary  electrical 
applications  are  of  doubtful  efficacy.  Electrolytic  interference,  however, 
where  uterine  fibroids  or  polypi  are  the  cause  of  the  excessive  flow  not 
infrequently  effects  most  marvellous  changes.    Ou  the  other  hand,  when 


392  ELECTRICITY  IN  GYNECOLOGY. 

an  excessive  flow  occurs  (especially  toward  the  decline  of  sexual  activity), 
partially  dependent  perhaps  on  inactivity  of  the  liver  or  constipation  and 
associated  with  a  degree  of  nervous  exhaustion,  the  indications  are  self-evi- 
dent, and  are  excellently  met  by  the  powerful  constitutional  tonic  effects 
of  general  faradization.  A  notable  illustration  of  the  remarkable  results 
that  may  follow  treatment  in  such  condition  was  illustrated  in  a  com- 
plicated case  that  I  once  saw  with  Dr.  W.  G.  Ailing.  The  patient  was 
a  married  woman,  aged  forty-six,  who  for  at  least  four  years  had  suf- 
fered at  each  menstrual  period  a  frightful  loss  of  blood.  The  imme- 
diate effects  were  to  render  her  completely  colorless  and  almost  pulseless, 
from  which  she  slowly  rallied,  to  be  again  similarly  reduced  by  a  return 
of  her  courses.  It  is  quite  evident  that  if  menstruation  had  occurred 
every  four  weeks,  the  patient  could  hardly  have  survived  for  so  long 
a  time  her  repeated  depletions;  as  it  was,  she  was  just  enabled,  by  the 
aid  of  a  good  appetite  and  vigorous  digestion,  to  regain  a  measure  of 
strength  and  color  before  the  recurrence  of  her  trouble.  The  intervals 
between  the  recurrences  of  menstruation  were  ordinarily  from  six  weeks 
to  two  months.  I  began  treatment  by  general  faradization  in  the  decline 
of  one  of  these  hemorrhages  for  the  relief  of  the  persistent  insomnia 
resulting  from  her  aneemic  condition.  It  aided  very  greatly  in  inducing 
sleep  and  relieving  pain,  and  markedly  hastened  returning  strength. 
Shortly  after  these  tentative  applications  were  begun  I  met,  at  the  house 
of  the  patient,  Dr.  Ailing,  under  whose  care  she  had  been  a  short  time 
before,  and  from  whom  she  had  received  continued  and  judicious 
treatment,  both  constitutional  and  local,  but  without  decided  relief. 
The  uterus  was  found  to  be  three  and  a  half  inches  in  length  and 
slightly  retroverted,  and  when  the  probe  was  carried  into  the  cavity  at 
the  first  examination  slight  hemorrhage  followed  its  withdrawal  and  a 
small  fungoid  mass  came  away.  Further  examination  revealed  consid- 
erable fungoid  degeneration  of  the  mucous  membrane. 

I  proposed  alternating  the  general  treatment  with  intravaginal  and 
mild  iutra-uterine  applications  (five  to  eight  milliamperes).  This 
method  of  procedure  was  repeated  up  to  the  day  of  menstruation,  the 
patient  in  the  mean  while  having  regained,  with  far  more  than  ordinary 
rapidity,  her  color  and  strength.  The  flow  Mas  considerably  more 
profuse  than  normal,  but  could  not  be  compared  in  severity  with  those 
that  had  previously  occurred.  In  ten  days  the  flow  ceased,  and  treat- 
ment was  continued  until  the  return  of  the  catamenia,  when  a  still 
greater  improvement  was  evident.  For  three  months  this  treatment 
was  kept  up,  when  the  patient  left  the  city  for  the  summer  with  the 
feeling  that  her  recovery  was  an  assured,  if  not  an  accomplished,  fact. 
Several  years  have  since  elapsed,  but  there  has  never  been  a  recurrence 
of  these  hemorrhages,  and  the  patient  has  at  all  times  since  been  in 
the  enjoyment  of  excellent  if  not  robust  health. 


OVARITIS  AM)    OVAIIIAN  NEURALdlA.  393 

Ovaritis  and  Ovarian  Neuralgia. 

Rensoiiiiii;-  iVom  Miialouv  and  I'loiii  the  wdl-kiiuw  n  ])liysicai  and 
pliysiolon-ical  c'lU'cIs  ol'  t'lccti-icity,  i(  is  (|ui(r  certain  tlial  this  a^(•nt,  in 
sonic  lorni  and  1)V  some  of  (lie  various  inetliods  oi"  a|)|)lication,  ou;;lit 
to  liavc  a  certain  \'aliic  in  o\arian  ncnraii^ia,  and  cncu  in  I  lie  .subacute 
and  chronic  varieties  of  ovaritis.  Kxpcriciice  very  positively  confirms 
these  tlieorctical  suj!;<;-estioiis,  hut  \)\  no  means  so  uiiilormly  as  in  con- 
gestions and  neuralt2;ic  pains  of  a  more  siiperlicial  <  haiacter.    , 

In  anv  ,<>;ivcu  ca.se  of  chronic  ovarian  pain  it  is  impossihle  to  speak 
positively  in  rcu'ard  to  the  measure  of  heiicHt  to  l)e  obtained  by  tiie  use 
of  electrieitv.  'I'iie  only  tliinu:  to  do  is  to  make  an  cllbrt,  and  in  a  cer- 
tain proportion  of  cases  the  results  obtained  will  abundantly  reward  us 
for  the  labor  expended. 

Nor  is  it  always  possible  to  decide  beforehand  what  form  of  electricity 
or  Avhat  methixl  of  aj^plication  is  specially  indicated.  In  the  treatment 
of  neuralgic  pains  in  general  I  have  found  that  certain  symptoms,  read- 
ily enough  elicited,  are  of  much  value  in  enabling  one  to  decide  as  to  the 
hind  of  electricity  needed.  Reference  is  made  to  the  effects  of  pressure, 
■wliii'h  generally  either  increases  the  pain  or  to  a  greater  or  less  extent 
affords  a  sense  of  relief.  In  the  first  instance  galvanism  almost  inva- 
riably is  to  be  preferred  to  faradism  in  the  local  application,  although 
the  faradic  current  in  many  of  these  cases  may  be  ap})lied  Avith  ad- 
vantage by  the  method  of  general  faradization.  The  surface  stim- 
ulation has  an  undeniably  beneficial  action  as  a  derivative,  probably 
through  the  reflex  influence  exerted,  Avhile  the  generally  sedative  and 
at  the  same  time  tonic  action  of  thorough  applications  is  often  .seen 
in  an  equalization  of  the  circulation  and  consequent  relief  of  local 
congestions. 

On  the  contrary,  in  those  forms  of  pain  M"here  firm  and  prolonged 
pi-essure  is  followed  by  a  sense  of  relief  the  faradic  current  locally  ap- 
plied is,  as  a  rule,  far  more  efficacious.  In  many  cases  of  this  kind  I 
liave  even  known  galvanism  to  aggravate  the  distress.  This  principle 
as  to  the  effects  of  pressure,  although  by  no  means  an  ab.solute  law,  is 
an  exceedingly  useful  guide  in  differentiating  between  the  two  forms 
of  dynamic  electricity  for  the  relief  of  external  neuralgia ;  and  in  the 
same  way,  although  perhaps  to  a  less  extent,  I  have  found  it  valuable 
in  the  consideration  of  the  treatment  of  ovarian  ]xiin.  As  illustrating 
this  point,  I  briefly  refer  to  the  case  of  a  young  lady  .sent  me  by  Dr.  T. 
G.  Thomas.  This  jmtient  was  and  had  been  suffering  for  months  from 
a  pain  of  a  dull,  aching  character  in  the  region  of  the  left  ovary.  No 
internal  apjilication  was  made  by  me :  I  therefore  cannot  say  as  to  the 
sensation  that  might  have  been  produced  by  pressure  more  directly 
against  the  ovary,  but  from  without  the  deepest  and  firmest  pressure 


394  ELECTRICITY  IN  GYNECOLOGY. 

was  followed  by  no  sense  of  discomfort ;  on  the  contraiy,  such  pressure 
was  felt  to  be  a  grateful  relief.  Local  applications  of  the  faradic  cur- 
rent through  a  period  of  several  weeks  appreciably  relieved  the  pain, 
but  failed  to  entirely  dissipate  it.  Franklinism  was  now  resorted  to. 
The  patient,  seated  on  the  insulating  stool,  was  subjected  to  a  surface 
stimulation  over  the  affected  part,  and  with  the  result,  after  a  few  appli- 
cations, of  entirely  and  permanently  relieving  the  distress  for  which 
relief  had  been  sought. 

It  is  in  deep-seated,  dull,  and  aching  pains  that  franklinism  by 
means  of  the  roller  electrode  is  especially  efficacious,  and  in  some  cases 
of  ovarian  pain  where  pressure  does  not  increase  the  distress  it  is  more 
efficacious  than  faradism.  In  an  undoubted  case  of  chronic  ovarian 
inflammation,  however,  galvanism  is  without  doubt  far  more  efficacious 
than  the  other  forms  of  electricity,  and  in  doses  of  from  ten  to  twenty- 
five  milliamperes  is  often  followed  by  most  grateful  relief. 

Subinvolution,  Superinvolution,  and  Atrophy. 

That  nutrition  may  be  variously  modified  by  electricity  is  now  an 
accepted  fact,  and  yet  its  action  upon  normal  and  abnormal  tissue  may 
be  diametrically  opposite.  This  apparently  paradoxical  action  of  elec- 
tricity is  no  new  thing.  We  constantly  find  that  it  relieves  both  anaes- 
thesia and  hyperesthesia.  It  is  used  successfully  to  excite  torpid  excre- 
tory processes,  and  also  to  restrain  this  function  when  too  active.  In 
the  same  way  it  may  cause  increase  or  it  may  cause  diminution  in  the 
size  of  a  part  or  organ.  Goitres,  for  example,  are  readily  reduced  in 
size,  and  sometimes  entirely  disappear,  under  simple  external  galvan- 
ization ;  and  so  with  other  forms  of  morbid  growths.  On  the  other 
hand,  it  is  well  known  to  all  whose  experience  has  been  at  all  extended 
that  normal  tissue  may  be  surprisingly  developed  by  jDersistent  local 
application. 

It  is  perhaps  not  out  of  place  to  say  here,  as  an  illustration  of  this 
point,  that  the  arms  of  the  author  have  been  much  increased  in  size, 
and  even  strength,  by  the  frequent  action  of  a  current  of  faradism  on 
them  through  a  series  of  years  in  the  line  of  professional  work.  Guided, 
then,  by  this  experience,  we  may  reasonably  expect  that  more  or  less 
benefit  will  follow  the  application  of  electricity  in  the  opposite  condi- 
tions of  sub-  and  suj^erinvolution,  and  also  in  atrophy  of  the  uterus. 
In  superinvolution  I  have  had  satisfactory  experience  in  but  one  case, 
where  the  condition  was  due  to  a  dangerous  and  difficult  labor  in  which 
it  became  necessary  to  dismember  the  child.  For  two  years  menstru- 
ation had  appeared  but  two  or  three  times,  and  upon  measurement  the 
uterus  was  found  to  be  but  about  one  and  three-fourths  of  an  inch  in 
length.     The  patient  was  treated  almost  daily  for  about  three  months 


SVBLWOLUTIOy,   SUI'ERISVOIJ'TIOy,   AXJ)   ATI'JU'IIY.     300 

l>y  iiittTiial  :ij)j»lic:i(i(»iis  ot"  hulli  farailisni  and  jralvaiiisin,  wlicii  a  sli<;lit 
show  apjK-aivil.  The  neirative  pole  wits  used  directly  {o  the  uterus  per 
vajjjinani,  and  od'a-sionaliy  intru-uterine  applieiitions  were  made.  At 
the  next  nienstiniation,  a  lew  weeks  sui)S((juently,  the  How  was  nuieh 
more  abundant.  1  rej^ret  to  siiy  that  alter  the  first  month  I  nej^leeted 
to  repeat  the  measurement,  and  since  the  rather  sudden  diseontinuanc« 
of  treatment  no  opportunity  has  presented  itself,  The  rcap|)earance  of" 
menstruatiou  would,  however,  seeui  to  be  sufHeieut  evidence  of"  the  entire 
success  of  the  efforts  made. 

Dr.  Fordyce  Barker,  in  some  remarks  made  In'forc  a  late  meetin*::  of 
tlic  Amerieau  Gynecological  Society  on  superinvolution,  declared  that 
but  a  small  proportion  of  cases  could  be  benefited  by  any  method  of 
treatment.  In  his  o|)inion  very  little  could  be  accomplished  when  the 
difiiculty  was  associated  with  evidence  of  arrested  or  defective  ovulation, 
while  in  those  cases  where  benefit  was  derived  there  w'as  always  evi- 
dence of  active  ovulation.  He  enumerated  as  symj)toms  of  the  exist- 
ence of  ovulation  associated  with  superinvolution  disturbance  of  the 
vascular  or  nervous  system  at  or  near  the  menstrual  period,  such  as 
intense  headache,  flushing  of  the  face  and  congestion  of  the  eye,  pelvic 
pain  and  sense  of  dragging,  with  nausea,  vomiting,  etc.  In  the  fore- 
going case  some  of  these  symptoms  were  distinctly  marked,  and  so  far 
forth  are  confirmatory  of  Dr.  Barker's  experience.  At  stated  periods 
there  were  severe  headache,  pelvic  pains,  aud  nausea ;  associated  with 
these  symptoms,  and  far  more  persistent  than  any  of  them,  was  intense 
melancholia.  With  the  return  of  menstruation  all  these  disturbing: 
symptoms  disappeared. 

In  subinvolution  of  the  uterus  my  experience  has  been  somewhat 
greater.  Among  several  cases  where  undoubted  amelioration  occurred 
I  have  in  mind  one  in  particular  which  Dr.  T.  G.  Thomas  saw  with 
me  aud  pronounced  to  be  one  of  subinvolution.  The  menstruation 
was  excessive,  with  abundant  leucorrhoea,  together  with  other  symj)toms 
attributed  to  the  size  and  weight  of  the  organ.  Occasional  local  appli- 
cations of  the  galvanic  current  wrought  within  a  few  months  a  verv 
great  change  in  the  condition  of  things.  The  menstruation,  instead  of 
being  excessive  and  continuing  for  nearly  a  week,  became  almost  scantv, 
with  a  duration  of  only  twenty-four  horn's,  the  leucorrhoea  ceased  to 
annoy  her  to  any  extent,  and  the  various  other  symptoms  supposed  to 
be  dependent  upon  the  enlarged  uterus  entirely  disapi)eared.  In  most, 
if  not  all,  cases  of  subinvolution  we  must  depend  mainly  ujion  the  gal- 
vanic current,  although  the  faradio  current  is  by  no  means  useless.  The 
negative  pole  is  applied  internally,  and  a  strength  of  from  twenty  to 
forty  railliamperes  is  amply  sufficient. 


396  ELECTRICITY  IN  GYNECOLOGY. 

Uterine  Displacements. 

That  electricity  is  capable  of  being  utilized  far  more  than  it  ever  has 
been  in  the  various  forms  of  uterine  displacement,  in  this  country  at 
least,  there  can  be  but  little  doubt.  The  rationale  for  its  use  is  indeed 
so  clear  that  from  the  standpoint  of  theoretical  considerations  alone  one 
might  be  pardoned  for  regarding  it  as  almost  a  specific  in  this  class  of 
cases. 

The  two  most  important  factors  that  make  up  the  value  of  electrical 
applications  in  displacements  are  probably  the  hypersemia,  and  especially 
the  contraction  of  muscular  fibre,  that  follow  its  use ;  and  as  the  con- 
traction of  a  muscle  determines  the  amount  of  its  nutrition,  it  follows 
that  if  a  current  of  electricdty  is  localized  in  a  given  point  of  the  uterus, 
that  part  will  contract,  its  nutrition  be  improved,  and  at  the  same  time 
counteract  any  flexion  in  the  opposite  direction.     It  must  be  confessed, 
however,  that  even  in  experienced  and  competent  hands  the  results  of 
electrical  treatment  in  this  special  field  have  not  equalled  the  brilliant 
promises  of  some,  and  especially  of  Tripier,  who  has  written  much 
upon  this  topic.     As  the  effects  we  desire  in  these  cases  are  purely 
mechanical,  the  faraclic  current  is  the  form   indicated.     The  simplest 
and   probably  least  efficacious  method  is  to   introduce   one  electrode 
behind  the  os  uteri,  while  the  other  is  applied  externally  over  either 
the  pubes  or  the  sacrum.     As  the  internal  electrode  is  larger  than  that 
employed  in  intra-uterine  applications,  and  the  mucous  surface  not  so 
sensitive,  a  much  stronger  current  can  be  employed ;  and  so  far  forth 
this  method  has  an  advantage  over  applications  to  the  interior  of  the 
uterus.    In  prolapsus  uteri  much  benefit  has  often  followed  this  method 
of  treatment  by  the  tone  imparted  to  the  relaxed  vaginal  walls.     A 
more  effective  localization  of  the  current  is  accomplished  by  introdu- 
cing one  electrode  into  the  uterus,  while  the  other  is  placed  externally ; 
but  more  effective  still  is  the  internal  use  of  both  poles.     In  cases  of 
anteflexion,  one  pole,  the  curve  of  its  stem  corresponding  to  that  of  the 
sacrum,  is  introduced  into  the  rectum  up  to  the  point  nearest  the  poste- 
rior wall  of  the  uterus.     In  this  way  the  current  is  quite  accurately 
localized  in  the  posterior  uterine  wall,  causing  contraction  and  improv- 
ing nutrition.      In  retroflexion  the  first  electrode,   instead  of  being 
passed  into  the  rectum,  is  introduced  into  the  bladder  and  applied  to 
the  anterior  wall  of  the  uterus.     When  the  faradic  current  is  used — 
and  this  form  is  chiefly  indicated — the  relative  positions  of  the  poles 
would  seem  to  be  of  no  special  importance,  although  for  the  intra- 
uterine electrode  the  anode  is  preferred  by  some,  on  the  theory  that  it 
has  a  greater  power  over  uustriped  muscular  fibre.     Tripier,  however, 
recommends  that  the  negative  pole  be  placed  in  the  uterus,  because  it 
is  the  stronger  (in  the  sense  of  being  more  powerfully  felt). 


J'F.llirTKIlIM':   Il.h'MATOCKfJ-:.  397 

'riu'  pain  is  soinetinies  coiisidiTal)!!',  and  is  due  (o  I  \\i»  causes :  1st, 
the  coiicciitrali'd  action  of  the  electricity  on  the  nincoiis  incniliranc;  2(1, 
the  contraction  of  tlic  ntci'inc  librcs.  In  other  cases  vi^vy  little  dis<'oin- 
I'ort  is  prodnccd.  \W  l)e<:;innin<;'  with  a  ycyy  weak  current  and  ;;i-adu- 
allv  increasintr  it  a  much  >'Tt!ater  stren<«lh  can  he  endured  than  if  this 
preeaution  is  not  ohserved.  In  this  eoinieetion  it  may  he  pertinent  to 
the  suhjeet  to  say  that  when  voluntary  nuiscles  are  subjected  to  the 
action  of  the  poles  of  oitluir  a  <;alvanic  or  eleetro-nia<;netic  battery  con- 
tractions instantly  occur.  Those  contractions  continue,  as  is  well  known, 
durinji;  the  passage  of  the  faradi<'  cm-rent,  but  quickly  relax  after  the 
fii"st  shock  of  the  o-alvanic.  When,  on  the  contrary,  invohnitary  mus- 
cular librc  <»f  which  the  uterus  is  composed  is  subjected  to  the  influence 
of  the  electric  current  movements  are  not  induced  until  a  certain  time 
after  the  tissues  have  been  acted  upon.  The  movements  thus  excited 
continue  for  a  time  after  the  cessation  of  the  current,  and  do  not,  as 
in  the  case  of  voluntary  nmscles,  cease  as  soon  as  the  electrodes  are 
removed. 

It  lias  been  observed  time  and  time  again  in  the  electrical  treatment 
of  uterine  affections,  when  the  local  method  only  has  been  used,  that 
marked  effects  upon  the  general  system  have  been  produced  and  severe 
symptoms  of  hysteria,  neuralgia,  and  nervousness  have  been  greatly 
ameliorated.  If  with  the  local  we  combine  the  general  or  central  treat- 
jnent  to  Mhicli  allusion  has  already  been  made,  these  constitutional 
effects  become  much  more  marked.  An  interesting  point  to  which  I 
have  given  much  observation  relates  to  various  nervous  symptoms 
and  certain  pathological  conditions  of  the  female  generative  organs 
as  they  are  connected  as  cause  or  effect. 

This  subject  need  not  l)e  discussed  here  further  than  to  refer  to  the 
difficulty  that  is  frequently  experienced  in  forming  a  correct  opinion 
as  to  whether  various  neuralgias  and  other  kinds  of  pain,  together  Avith 
certain  characteristic  nervous  derangements  associated  with  uterine  dis- 
orders, exist  independently  or  are  dependent  upon  such  disordei-s.  Too 
frequently,  without  doubt,  such  dependence  does  exist,  and  all  efforts  to 
alleviate  the  nervous  symptoms  prove  more  or  less  futile  until  the  orig- 
inal uterine  difficulty  has  been  overcome.  In  other  cases,  as  I  have 
demonstrated  to  my  satisfaction  many  times,  severe  hysterical  symp- 
toms, neuralgias,  etc.,  supposed  to  be  entirely  dependent  upon  disease 
of  the  uterus  or  its  appendages,  recover  in  great  degi-ce  under  electrical 
treatment,  while  yet  no  progress  has  been  made  in  the  purely  local 
treatment. 

Periuterine  Hematocele. 
Apostoli  treats  these  tumors  by  the  chemical  caustic  action  of  the 
negative  pole.     A  non-retractile  fistula  is  thus  made,  the  tendency  of 


398  ELECTRICITY  IN  GYNECOLOGY. 

which  is  to  remain  open  and  with  adhesions  between  the  pathological 
cavity  and  the  external  mucous  niembrane.  The  strong  caustic  action 
obtained  by  this  method  modifies  the  nutrition  of  these  pathological 
cavities  and  leads  to  rapid  retrograde  metamorphosis.  The  method  is 
quick  in  action,  and  he  claims  for  it  perfect  safety.  It  is  a2")plicable 
as  well  to  abscesses,  fibromata,  interstitial  myomata,  and  extra-uterine 
cysts. 

Ovarian  and  Fibroid  Tumors,  Polypi,  etc. 

In  ovarian  and  fibroid  tumors  the  electrolytic  method  is  undoubtedly 
worthy  of  consideration,  although  the  results  have  not  as  yet  been  suf- 
ficiently satisfactory,  in  ovarian  tumors  at  least,  to  commend  themselves 
strongly  to  authorities  in  the  department  of  uterine  surgery.  The  fol- 
lowing is  an  extract  from  a  resume  of  what  has  been  attempted  and 
accomplished  in  the  electrolytic  treatment  of  ovarian  tumors  :  ^  "  1st.  A 
number  of  ovarian  tumors  reported  on  reliable  authority  have  been 
completely  cured  or  permanently  improved  by  electrolysis;  twenty- 
eight  out  of  fifty-one  cases,  or  about  55  per  cent.  2d.  In  a  number 
of  these  cases  electrolysis  was  followed  by  dangerous  (thirteen,  or  25.4 
per  cent.)  and  even  fatal  results  (nine  out  of  these  thirteen,  or  17.6 
per  cent,  of  the  whole  fifty-one).  3d.  Further,  six  cases  out  of  fifty- 
one  received  neither  benefit  nor  injuiy  from  the  treatment,  and  four 
were  only  temporarily  improved;  total,  ten,  or  19.6  per  cent.  We  thus 
have  a  total  of  twenty-three  cases,  or  45  per  cent.,  in  which  the  elec- 
trolytic  treatment   failed    to    accomplish  the  object  for  which  it  was 

administered 6th.  Notwithstanding  these  undoubted  cures  the 

percentage  of  successes  of  oophoro-electrolysis  (55  per  cent.)  compares 
unfavorably  with  that  of  ovariotomy  (70  to  80  per  cent. ;  Spencer 
Wells,  78  per  cent. — in  1876  as  high  as  91  percent.)  And  so  also 
do  the  deaths  by  electrolysis  (17.6  per  cent.)  nearly  equal  those  fol- 
lowing ovariotomy  in  recent  years  (20  to  30  per  cent.,  to  22  per  cent.), 
and  far  exceeding  those  occurring  in  the  last  series  of  fifty-five  cases  of 
Spencer  Wells  (5  or  9  per  cent.)" 

The  method  of  operation  in  these  cases  is  simple,  and,  with  a  proper 
knowledge  of  electro-physics  and  a  greater  experience  in  the  details  of 
treatment,  it  goes  without  saying  that  better  results  ought  finally  to 
reward  efforts  in  this  direction.  While  the  percentage  of  cures  by 
electrolysis  could,  in  all  probability,  never  rise  as  high  as  in  ovariot- 
omy, fatal  results  ought  to  be  reduced  to  a  minimum.  In  other  words, 
in  those  cases  where  no  benefit  accrues  I  believe  it  to  be  quite  possible 
to  avoid  injury  in  nearly  all  cases. 

In  the  treatment  of  uterine  fibroids  by  electrolysis  we  can  rarely 

i"TheValne  of  Electrolysis  in  the  Treatment  of  Ovarian  Tumors,"  Gynecological 
Transactions,  1878,  by  Paul  F.  Munde,  M.  D. 


or.iAv.i.v  .Lv/>  Fin  no  1 1)  tumors,  polypt,  etc.         399 

li(>|K'  to  see  tliein  (lis:ii)]M:ii'  entirely  ;  iii(lee<l,  where  onliiiarv  surf!:ieal 
proeedure  is  possiMe  there  is  no  reason  lor  atteniptint;- this  nietho(L  Jii 
some  eases  ot"an  intraninral  character,  liowever,  where  radical  operative 
stej)s  are  inadmissihle,  luiicli  can  lie  aeeoinplished  lor  the  relief  of  the 
patient.  1  have  referred  elsewhere'  to  the  very  enconra^in^  resnlts 
obtained  in  several  such  eases,  hut  in  no  instance  was  tin-  relief  more 
marked  than  in  a  recent  ease,  whieli  is  worthy  of  record  as  illustrative 
of  the  <ireat  Ix-nelit  that  mav  result  from  the  metliod  : 

The  patient,  a  maiilen  lady  aged  forty-seven,  had  begun  to  suffer  in 
this  way  many  years  before.  She  had  consulted  various  authorities 
both  liere  and  abroad — in  this  country  Dr.  T.  Addis  Emmet,  who  pro- 
nounced it  a  case  of  intramural  fibroid.  Without  attempting  to  give 
dimensions,  it  is  sufficient  to  say  that  the  tumor  was  quite  large,  and 
while  it  interfered  greatly  with  easy  and  rapid  locomotion,  this  was  of 
little  consequence  compared  to  the  inconvenience  and  actual  distress  due 
to  pressure  both  on  the  rectum  and  bladder.  The  cervix  uteri  was  greatly 
enlarged,  and  almost  like  cartilage  in  the  sensation  it  gave  to  the  touch  : 
as  a  result,  she  sutfered  much  from  incontinence  of  urine,  while  the 
constipation  was  excessive  and  had  to  be  relieved  by  frequent  injections. 
The  benefit  following  the  absorptive  action  of  the  galvanic  current  in 
this  case  was  most  marked.  The  neck  of  the  uterus  became  appreciably 
softer  and  very  decidedly  reduced  in  bulk,  and  the  patient  returned  to 
her  home  almost  entirely  relieved  of  the  distressing  symptoms  from 
which  she  had  suffered  so  long. 

In  those  cases  where  it  can  be  readily  accomplished  the  electrolytic 
method  may  be  attenijited,  and  in  a  certain  proportion  of  cases  radical 
results  have  been  said  to  follow.  The  very  strongest  currents  must  be 
used,  but,  notwithstanding,  in  the  majority  of  cases  fibroid  tumors, 
whether  internal  or  external,  will  not  entirely  disappear,  even  under 
the  most  thorough  electrolytic  treatment. 

External  fibroid  tumors  indeed  are  hard  and  drv — rlo  not  in  anv  case 
readily  respond  to  electrolytic  action.  In  uterine  fibroids,  however,  the 
process  of  absorption  seems  to  be  more  readily  excited  bv  electrolvsis, 
and  the  treatment  is  worthy  of  more  extended  trial  in  cases  not  suitable 
for  the  knife.  There  can  be  no  question  that  by  means  of  negative 
electro-puncture,  and  Avith  currents  of  the  strength  of  forty  or  fifty 
milliamperes,  uterine  ]iolypi  can  be  successfully  treated.  Both  Apostoii 
of  France  and  Engelmann  of  this  countr\-  use,  however,  much  stronger 
currents  than  this  in  the  electrolytic  treatment  of  fibroid  tumors.  Engel- 
mann claims  to  have  used  as  high  a  strength  as  two  hundred  and  fiftv 
milliamperes  with  no  ill  effect.  It  can  seldom,  if  ever,  however,  be 
necessary  to  attempt  such  heroic  treatment  as  this,  but  if  ever  attempted 
it  should  be  only  through  a  gradual  increase  of  the  current-intensity. 
^  Lectures  on  Medical  and  Surgical  Eleclricity,  p.  106. 


400  ELECTRICITY  IN  GYNECOLOGY. 

In  order  that  such  extraordinary  intensity  of  cuiTent  may  not  cause 
great  pain,  Apostoli  uses  an  electrode  for  external  application  sufficiently 
large  to  almost  entirely  cover  the  abdomen.  This  electrode  is  sculptors' 
clay,  held  in  place  by  gauze.  A  material  easily  obtained,  and  answer- 
ing perhaps  equally  well,  is  absorbent  cotton.  A  thin  layer,  sufficient 
to  retain  a  moderate  amount  of  moisture,  may  be  placed  upon  a  large 
flexible  metal  electrode,  the  cotton  being  covered  by  chamois-skin.  In 
the  electrolysis  of  fibroid  and  other  tumors  the  needle  to  be  introduced 
into  the  tumor  should,  as  a  rule,  be  connected  with  the  negative  pole. 
There  can  indeed  be  very  few  exceptions  to  this  rule. 

Apostoli  teaches  that  if  hemorrhagic  tendencies  exist  the  positive 
needle  should  be  used,  since  the  effect  of  the  positive  pole  is  to  arrest 
hemorrhage  through  coagulation.  If  the  tumor  is  easily  accessible, 
needles  connected  with  both  poles  may  be  introduced  into  the  tumor. 
Engelmann  teaches  that  if  profuse  menorrhagia  or  metrorrhagia  be 
associated  with  fibroids,  these  tendencies  must  be  overcome  by  positive 
electro-cauterization  before  resoi'ting  to  electrolysis.  A  platinum  sound 
is  used,  and  a  current  of  one  hundred  milliamperes  is  applied  to  the 
uterine  cavity. 

In  applying  the  positive  pole  to  mucous  membranes,  platinum  or 
gold  should  always  be  used,  since  other  metal  electrodes,  such  as  silver, 
copper,  or  steel,  readily  become  oxidized  and  imbedded  in  the  tissues. 
In  the  positive  electro-cauterization  of  hemorrhagic  fibroids,  which 
should  precede  negative  electro-puncture,  the  rule  is  to  use  a  current- 
strength  of  one  hundred  milliamperes  or  thereabouts.  If  a  copper  or 
silver  probe  is  used,  the  strength  must  be  much  less,  not  over  ten  or 
fifteen  milliamperes. 

For  the  electrolytic  treatment  of  fibroid  tumors,  says  Engelmann, 
the  ^'electrodes  needed  are  a  gold  or  platinum  sound  of  ordinary 
dimensions,  and  a  needle  or  stylet  of  the  same  material  (though  the 
steel  instrument  may  be  used),  well  fixed  in  a  firm  handle ;  for  punc- 
ture through  the  vagina  this  instrument  should  be  of  a  length  equal 
to  that  of  other  gynecological  instruments,  sound  or  applicator;  for 
both  sound  and  stylet  we  must  have  a  separate  insulator  of  heavy 
rubber — better  still  of  glass,  which  may  be  kept  more  thoroughly 
aseptic.  The  abdominal  or  dispersing  electrode  is  a  thin  plate  of  lead 
or  tin  alloy,  as  large  as  it  can  be  used  upon  the  abdomen,  averaging 
six  by  nine  inches,  covered  with  a  thin  layer  of  sculptors'  clay  held 
in  place  by  gauze,  or  with  punk  or  absorbent  cotton  and  a  soft,  thin 
buckskin  cover,  which  is  equally  good." 

"  The  shape  which  admits  of  the  use  of  the  largest  possible  plate  is 
the  oval,  or,  better  still,  the  modified  form  of  my  plate,  oval  with  con- 
vexities to  avoid  the  thighs.  This  electrode  is  thoroughly  soaked  in 
water  as  warm  as  is  comfortably  borne,  and  snugly  adapted  to  the 


OVARfAX  AXD   FinnOID    Tl'}fOnS,    rOLYPT,   ETC.  401 

abdomen,  that  it  may  rest  in  j)la('o  a  icw  miiiutcs  hcCoro  treatment  is 
bcj^un,  the  eurrent  tlicn  juussinj:^  more  readily,  witli  le.s.s  j)ain  ;  the  fric- 
tion, as  I  may  say,  caused  by  the  efforts  of  the  electric  current  to  pjuss 
the  resistance  oHered  by  the  dry  epidermis  bein*;  possibly  a  source  of 
pain,  certainly  lessening  the  effect  of  the  current  by  loss  of  intensity  in 
overcoming  th(;  greater  resistance.  If  this  precaution  is  not  observed, 
the  operator  will  find  an  intense  burning  din-ing  the  first  few  minutes, 
which  lessens,  however,  as  the  tissues  beccjme  soaked;  the  desired 
intensity  having  been  attained,  notwithstanding  that  no  more  cells  are 
inserted  into  the  circuit,  the  galvanometer  will  indicate  an  increase  in 
high  intensities  of  as  much  as  ten  milliamperes,  and  yet  the  pain  lessens 
decidedly  if  the  positive  be  the  dispersing  pole.  I  have  even  seen  it  rise 
from  fifty  to  a  hundred  milliamperes,  without  augmenting  the  number 
of  cells,  when  the  abdominal  plate  had  not  been  placed  until  the  last 
moment,  so  that  the  dry  epidermis  offered  a  resistance  at  first  difficult  to 
overcome.  In  other  words,  when  the  epidermis  becomes  soaked,  less 
resistance  is  offered,  more  electricity  passes,  and  if  the  positive  be  the 
dispersing  pole  the  pain  is  lessened  by  the  anaesthetic  effect  of  the  pole, 
diminished  at  times  to  a  minimum,  though  the  intensity  of  the  current 
be  increased.  Before  placing  this  plate  we  must  examine  the  abdomen 
to  see  if  it  shows  any  abrasions  or  excrescences  ;  if  so,  they  may  be 
covered  with  a  small  piece  of  oiled  silk  or  plaster,  as  such  a  spot  would 
be  the  centre  of  intense  pain  if  not  guarded.  An  abrasion,  a  small 
blister  where  the  epidermis  is  removed,  centres  upon  itself  much  of  the 
electric  force,  which  always  seeks  the  best  conductor ;  or  if  an  excrescence 
the  increased  pressure  would  cause  a  concentration  of  the  current  at  this 
point.  The  plate  having  been  placed,  it  is  covered  by  a  warm,  dry  towel 
or  a  piece  of  oiled  silk,  to  guard  all  garments  in  contact  with  it  from 
moisture,  which  may  lead  to  serious  colds,  to  injury,  as  well  as  mere 
discomfort." 

"  The  stylet  or  sound,  whichever  is  to  be  used,  is  steeped  in  a  strong 
antiseptic  solution,  as  is  also  the  glass  or  rubber  insulator ;  the  vagina 
also  should  be  cleansed.  For  electro-cauterization  the  sound,  covered 
up  to  two  inches  of  the  point  by  the  insulator,  is  introduced  into  the 
uterine  cavity  Avith  the  utmost  care ;  if  possible  it  is  preferable  to  intro- 
duce the  sound  by  the  sense  of  touch.  If  the  stylet  is  used  for  electro- 
puncture,  the  point  of  entry  having  been  carefully  decided  upon,  the 
instrument  is  introduced,  the  point  guarded  by  the  index  finger  of  the 
left  hand,  the  handle  grasped  firmly  by  the  right,  counter-pressure  being 
made  upon  the  abdominal  protuberance.  The  puncture  is  then  made  for 
a  depth  of  from  one  to  three  inches,  according  to  the  size  of  the  tumor; 
the  insulatino;  cover  is  moved  close  against  the  vaginal  and  cervical  mem- 
brane,  and  care  must  be  taken  that  the  entire  surface  of  the  instrument 
not  in  action  is  guarded.    The  activity  of  the  battery  is  now  tested ;  the 

Vol.  I.— 26 


402  ELECTRICITY  IN  GYNECOLOGY. 

rheophores  are  attached  to  the  electrodes  and  the  screws  firmly  bound ; 
the  galvanometer  needle  must  point  directly  to  zero.  The  abdominal 
plate,  evenly  adapted  everywhere,  is  held  down  with  gentle  pressure  by 
the  hands  of  the  patient,  while  the  operator  either  fixes  the  sound  or 
stylet  with  an  absolutely  steady  hand  or  rests  it  upon  some  suitable 
support,  as  the  slightest  motion,  any  jarring  of  cords  or  battery  in 
portable  batteries,  must  be  avoided.  The  patient  must  breathe  evenly 
and  steadily,  and  allow  her  hands  to  follow  the  respiratory  heavings  of 
the  abdomen ;  we  must  see  that  the  thighs  nowhere  touch  the  edge  of 
the  electrode,  and  if  perchance  the  probe  is  to  be  passed  through  a 
speculum,  the  slightest  contact  of  its  metal  surface  with  the  pole  must 
be  avoided.  When  any  pain  or  discomfort  that  may  have  been  caused 
by  the  introduction  of  the  instrument  has  ceased,  the  current  is  estab- 
lished and  gently  increased,  in  the  first  sitting,  in  the  course  of  a  minute 
up  to  fifty  or  a  hundred  railliamperes;  later,  when  the  sensibilities  of 
the  patient  have  been  tested,  one  hundred  and  fifty  to  two  hundred,  and 
even  two  hundred  and  fifty  milliamperes,  may  be  attained  in  the  same 
time.  For  very  sensitive  patients  I  use  the  water-rheostat,  by  means  of 
which  we  can  attain  the  desired  intensity,  increase  and  diminish  the  cur- 
rent, without  even  the  slight  shock  caused  by  the  addition  of  element 
after  element ;  a  resistance  of  five  hundred  or  one  thousand  ohms  is 
inserted,  the  number  of  cells  probably  needed  thus  brought  into  action, 
and  the  intensity  gradually  attained  by  decreasing  the  resistance  in  the 
rheostat ;  for  the  breaking  of  the  current  the  resistance  is  increased  until 
it  surpasses  the  intensity  of  the  elements  in  the  circuit." 

"  The  first  sitting  should  not  be  continued  beyond  five  minutes,  the 
current  remaining  at  its  height  three  minutes,  then  being  slowly  reduced. 
Currents  of  two  hundred  milliamperes  I  have  continued  for  eight  min- 
utes in  later  stages  of  the  treatment.  During  the  passage  of  the  current 
the  operator  must  constantly  observe  both  his  galvanometer  and  the 
patient.  The  needle  should  remain  perfectly  steady :  during  the  first 
minute  it  will  show  an  increase  of  a  few  milliamperes,  but  there  must 
be  no  oscillation,  which  indicates  jarring  or  shock.  The  face  of  the 
patient  and  the  galvanometer  must  be  constantly  observed,  and  tlie 
operator  must  be  on  the  lookout  for  any  evidence  of  irregularity  :  a 
momentary  contact  of  sound  and  speculum  would  produce  a  terrific 
shock.  If  the  bare  sound  should  touch  the  vaginal  membrane  it  would 
burrow  its  way  and  leave  a  grayish  bed ;  if  the  thighs  touch  the  edge 
of  the  abdominal  plate,  which  must  always  be  covered  by  the  overlap- 
ping conductor,  an  intense  burning  is  experienced — if  not  so  covered,  a 
shock ;  and  these  shocks  are  trying,  if  not  dangerous,  with  such  intensi- 
ties. The  most  intense  shock  is  caused  by  a  carelessness  of  which  no 
one  who  ventures  upon  this  treatment  should  be  guilty,  the  sudden 
breaking  of  any  one  of  the  connections  in  the  circuit,  the  dropping  of 


or.iA'/.i.v  .L\7>  riniioin  'iTMons,  rou'vi,  irra        403 

tlir  i-lio()i)lioro  iVniii  ilic  liiinliiiL:;-j)().st  at  the  battery  or  iVmn  tlw  clec- 
ti-odc,  or  tlio  iiKtvin^-  of  oiic  of  the  switches  nl"  tlic  hattcry.  In  a  port- 
able battery  especial  care  iiiiist  be  taken  lest  disturbaiiee  be  caused,  tl>e 
slii»litest  jar  dI"  llie  batterv  caiisini;-  iiiididatioiis  of  the  current  and  shock. 
At  the  point  at  which  the  stylet  is  inserted  a  <:;rayish-yellow  loam  will 
aecunudate,  its  mass  depending;  upon  the  intensity  and  duration  of  tlie 
current." 

"After  the  inll  intensity  has  l)Con  attained  and  continued  as  loiifj;  as 
it  seems  necessary,  the  current  is  slowly  reduced  i'rom  cell  to  cell  with 
the  utmost  evenness  and  gentleness,  and  the  eircuit  opened  when  at  0. 
If  the  |)atient  be  N'ery  sensitive  we  may  diminish  the  current  by  slowly 
increasing  the  resistance  by  the  water-rheostat.  When  the  current  has 
been  broken  the  rheophores  are  detached  and  the  aetive  interpelvic  pole 
is  first  removed  with  the  utmost  caution  ;  the  abdominal  plate  is  then 
taken  otf,  the  siu'culum  inserted,  and  the  vagina  cleansed. 

"  1  am  in  the  lial)it  of  dusting  the  cervix  with  iodoform  and  insert- 
ing a  tampon  of  salicylated  or  boratcd  cotton  ;  in  case  of  puncture  I 
use  the  styptic  iron  cotton  directly  upon  the  point  of  attack,  and  pack 
it  firndv  to  counteract  the  possibility  of  hemorrhage  as  far  as  possible. 
The  patient  should  then  lie  down  or  go  to  bed  if  at  her  home,  and,  if 
not,  as  soon  as  she  reaches  it;  but  in  all  events  she  must  rest  in  the 
office  long  enough  to  thoroughly  dry  her  garments,  which  are  more  or 
less  moistened  by  contact  with  the  electrodes  notwithstanding  all  care; 
in  cold  weather  this  precaution  must  be  invariably  observed,  as  serious 
injury  may  follow  neglect.  Twenty-four  hours'  rest  is  generally  all  that 
is  needed,  but  in  individuals  more  susceptible  it  is  well  that  they  use  the 
ice-bag  upon  the  abdomen  and  remain  in  bed  several  days.  The  inflam- 
matory swelling  which  sometimes  follows  is  thus  best  counteracted  and 
most  rapidly  reduced ;  l)ut  even  when  it  does  occur  I  have  never  seen  it 
accompanied  by  constitutional  disturbance  or  elevation  of  temperature. 

"  The  puncture  should,  if  possible,  be  made  through  the  cervix  into 
the  mass  of  the  tumor ;  if  the  first  is  above  the  os,  the  next  should  be 
below,  Ibllowed  by  one  to  the  right  and  then  to  the  left ;  if  this  is  not 
well  feasible,  we  seek  the  point  of  greatest  projection,  toward  the  vagina, 
avoiding  the  peritoneum.  In  some  cases  a  gush  of  blood,  very  ]>rofnse 
while  it  lasts,  but  not  of  long  duration,  may  take  place  within  the  ten 
hours  following  the  application,  and  the  patient  must  be  forewarned, 
that  she  may  not  be  alarmed.  The  firmly-packed  iron  cotton  tampon 
is  the  best  preventive,  but  the  hot-water  injection  should  also  be  recom- 
mended, as  the  patient  will  be  much  better  satisfied  to  have  some  means 
at  hand  to  counteract  this  apparently  threatening  symptom."^ 

By  this  method  Apostoli  and  Engelmann  have  treated  a  large  num- 

^  "Electricity  in  Gynecology,"  bj' George  J.  Engelmann,  Transactions  of  the  American 
Gynecological  Society,  1S86. 


404  ELECTRICITY  IN  GYNECOLOGY. 

ber  of  cases,  and  claim  most  excellent  results.  Although  the  tumor  is 
not  made  to  disappear,  in  nearly  every  case  groAvth  has  been  arrested, 
and  in  mauv  instances  the  size  of  the  tumor  markedly  diminished. 


Chronic  Cellulitis  and  Peritonitis. 

In  the  treatment  of  the  sequelfe  of  pelvic  inflammation  electricity  is 
not  infrequently  followed  by  the  most  satisfactoiy  results.  The  benefit, 
indeed,  to  be  derived  from  this  method  of  treatment  in  such  conditions 
is  only  indilferently  appreciated  by  gynecologists.  For  the  absorption 
of  old  exudations  in  other  parts  of  the  body,  the  galvanic  current  has 
long  been  known  to  be  most  efficacious,  but  only  within  a  comparatively 
recent  period  has  it  been  tested  in  the  thickening  and  infiltration  result- 
ing from  inflammation  of  the  pelvic  cellular  tissue.  The  negative  pole, 
consisting  of  a  metal  ball  or  concave  clasp,  is  to  be  used  internally. 

If  the  metal  electrode  is  applied  directly  without  the  intervention  of 
a  sponge  or  chamois  covering,  care  must  be  taken  not  to  use  currents 
sufficiently  strong  to  prodtice  eschars.  This  mishap  may  occur  even 
without  the  knowledge  of  the  patient,  and  it  is  therefore  always 
safer  to  use  a  covered  electrode.  I  have  seen  this  treatment,  judi- 
ciouslv  and  persistently  carried  out,  melt  away  not  only  large  pelvic 
deposits,  but  dissipate  a  most  severe  and  persistent  sciatica  that  had 
resisted  every  well-recognized  method  of  treatment,  and  restore  power 
to  limbs  wellnigh  paralyzed.  In  these  cases  both  sciatica  and  paralysis 
were  occasioned  by  the  pressure  of  the  exuded  material  upon  the  pelvic 
floor,  and  could  not  have  been  relieved  excepting  through  the  disappear- 
ance of  the  morbid  products.  A  current  strength  of  twenty  or  thirty 
milliamperes  is  usually  sufficient.  Apostoli  uses  negative  electro- 
puncture  in  these  cases,  and  very  strong  currents,  from  which  he  has 
seen  only  the  yery  best  results. 

Hyperplasia  Uteri. 

The  very  disagreeable  symptoms  that  are  so  often  associated  with  this 
intractable  condition  are  occasionally  vers'  much  ameliorated  by  the  per- 
sistent use  of  the  galvanic  current.  The  intra-uterine  electrode  may  be 
used,  but  the  current  must  be  weak  and  the  applications  short,  so  as  to 
avoid  unpleasant  electrolytic  effects.  As  a  rule,  however,  extra-uterine 
will  accomplish  quite  as  much  as  intra-uterine  applications.  The  dis- 
advantage of  the  applications  by  the  former  method,  that  it  is  not 
so  direct,  is  more  than  balanced  by  the  far  greater  tension  of  current 
that  can  be  used  when  with  a  large  sponge-covered  bulb  electrode  firm 
pressure  is  made  around  and  above  the  os  uteri.  In  one  case  of  hyper- 
plasia uteri  treated  some  months  since  the  benefit  accruing  from  persist- 


EXTRA-rTKiiisi:  rnjy.x.iycy.  40o 

ent  extra-utoriiie  applications  was  seen  in  a  greatly  incre{i.se<l  menKtrual 
flow  and  in  the  relief  of  severe  <j:astral<:;ia.  But  the  most  speedy  ami 
etleetive  nu'th(Kl  of  treat injr  areolar  liyperpl:L>;ia  is  hy  electrolysis.  One 
or  two  needles  may  be  thrust  into  the  hardenetl  tissues  parallel  to  the 
canal,  and  a  current  of  from  forty  to  sixty  milliamperes  usetl.  There 
can  Ik-  hut  little  (jucstion  that  the  needles  should  hy  [)relerence  be  con- 
nected with  the  net^ative  pole,  although  Menic^re  '  claims  to  have  treats! 
one  hundred  cases,  always  using  the  positive  as  the  active  pole;  but  as 
he  regards  six  months  as  the  average  time  required  for  the  treatment,  it 
is  evident  that  his  results  would  be  more  speedy  and  satisfactory  if  he 
used  the  negative  pole  for  its  electrolytic  action  and  the  positive  exter- 
nally. It  is  seldom  that  the  positive  pole  is  indicated  in  electrolytic 
operations,  unless  the  object  is  to  decrease  an  active  hemorrhage  or  to 
cause  a  blood-clot,  as  in  the  case  of  erectile  tumors.  The  positive  pole 
is  more  liable  to  cause  a  slough,  and  is  far  less  efficient  as  an  absorbent, 
than  the  negative. 

Other  conditions  for  which  the  galvanic  current  may  be  used  with 
liopes  of  beneficial  results  are  pachysalpingitis  and  lymphadenitis.- 
Apostoli  has  reported  some  cases  of  hsematocele  cured  by  this  method. 

Stenosis  of  the  Uterine  Canal. 

In  stenosis  of  the  uterine  canal  the  action  of  the  galvanic  current  is 
most  valuable,  and  iu  many  cases  is  sufficient  to  afford  complete  relief. 
I  have  treated  several  of  these  cases  by  electro-cauterization,  and  in 
each  instan(?e  Avith  most  satisfactoiy  results.  A  sound  of  the  proper 
size  having  been  introduced,  it  is  connected  Avith  the  negative  pole,  the 
positive  being  applied  to  the  abdomen.  A  strength  of  fifty  milliamperes, 
continued  for  five  minutes,  will,  as  a  rule,  be  found  sufficient.  In  my 
own  cases  the  number  of  applications  that  were  found  necessary  to  effect 
a  permanent  cure  ranged  from  six  to  twenty-five. 


Extra-uterine  Pregnancy. 

My  experience  in  the  treatment  of  extra-uterine  pregnancy  has  been 
given  elsewhere,^  hence  it  will  be  unnecessary  to  repeat  in  full  detail 
here  the  various  cases  that  serve  to  prove  the  feasibility  of  the  operation 
as  well  as  its  great  value.  That  the  destruction  of  fcetal  life  could  be 
easily  affected  by  electricity  admitted  of  no  doubt,  but  whether  it  was 
possible  to  do  this  without  in  any  way  injuring  the  mother  was  a  ques- 

^  Gazette  de  Gynecolngie,  Feb.,  1886. 

^  Dr.  Paul  F.  Mnnde  lias  reported  in  the  Amfricnn  Jovmnl  of  Obstetrics  for  Dec., 
1885,  some  very  interesting  cases  of  this  character  treated  by  electricity. 
^  A  Practical  Treatise  on  Medical  and  Surgical  Electricity,  etc.,  4th  ed. 


406  ELECTRICITY  IN  GYNECOLOGY. 

tion  that  could  be  determined  only  by  an  experimental  effort.  This 
opportunity  was  afforded  some  years  ago  by  a  case  in  the  practice  of 
Dr.  Charles  McBurney,  when  the  method  was  suggested  by  Dr.  T.  G. 
Thomas,  and  I  was  asked  to  superintend  the  operation.  The  case  was 
one  of  tubo-interstitial  pregnancy  at  the  third  month,  and  terminated 
favorably  by  the  expulsion  of  the  foetus  and  placenta  through  the  ute- 
rus. Subsequently,  eleven  other  cases  fell  under  my  observation,  all 
of  which  I  submitted  to  similar  treatment,  and  with  results  entirely  sat- 
isfactory. The  history  of  most  of  these  cases  will  be  found  recorded  in 
my  fifth  edition  of  Beard  and  Rockwell's  Medical  and  Surgical  Elec- 
tricity. In  one  of  these  cases  at  least  there  was  a  subsequent  conception, 
followed  by  a  safe  delivery  of  a  healthy  child.  In  these  operations  the 
galvanic  current  alone  was  used,  the  position  of  the  poles  varying  ac- 
cording to  the  position  of  the  foetal  mass,  and  the  strength  of  the  cur- 
rent according  to  the  susceptibility  of  the  patient  and  the  probable  dis- 
tension of  the  Fallopian  tube.  As  there  is  probably  no  remedy  to  the 
effects  of  which  there  are  such  different  degrees  of  susceptibility,  it  is 
impossible  to  do  more  than  approximately  state  the  current-strength 
called  for.  In  my  own  cases  the  current  varied  in  strength  from  ten 
to  twenty  milliamperes. 

An  interrupted  rather  than  a  continuous  current  is  to  be  employed, 
although  there  may  be  an  advantage  in  its  rapid  increase  by  means  of 
a  rheostat.  In  this  way  the  chemical  and  physiological  effects  are 
greatly  increased,  without  the  disagreeable  effects,  and  even  the  danger, 
that  might  accompany  an  interruption  of  the  same  strength  of  current. 
The  danger  to  be  apprehended  from  an  injudicious  application  of  the 
farad ic  or  the  interrupted  galvanic  current  is  the  possibility  of  ruptur- 
ing the  over-distended-  tube.  How  great  this  danger  is  it  is  impossible 
to  say,  but  that  the  possibility  exists  cannot  be  questioned.  In  one 
case,  where  the  pregnancy  had  advanced  nearly  to  the  fourth  month, 
the  necessity  for  caution  forcibly  presented  itself  to  me.  By  gradually 
increasing  and  as  gradually  decreasing  the  strength  of  the  current  I  was 
enabled  to  use  without  fear  a  power  of  twenty  milliamperes  where,  with 
interruptions,  I  had  feared  to  use  more  than  five.  In  regard  to  the 
position  of  the  poles,  my  custom  has  been  to  place  the  positive  exter- 
nally. This  should  consist  of  a  broad,  flat  sponge  pressed  firmly  on 
the  skin  and  directly  over  that  portion  of  the  tube  where  the  foetus  is 
developing.  The  negative  pole  is  used  internally,  and  may  be  carried 
up  to  the  foetal  mass,  either  through  the  vagina  or  rectum  according  to 
the  position  and  size  of  the  tumor. 

In  the  twelve  cases  that  I  have  recorded  the  operation  was  performed 
through  the  vagina  in  nine  and  the  rectum  in  three.  As  there  seems  to 
be  no  way  of  determining  positively  Avhether  the  foetal  life  is  immedi- 
ately destroyed  by  the  first  application,  it  has  been  customary  to  repeat 


EXTRA-UTERINE  PREGNANCY.  407 

it  three  or  four  times;  and   as  Imt   little  jtaiii   is  caused,  there  can  he 
no  special   ohjcftioii   to  its  repetition  on  this  scon*. 

All  nu'dical  and  snry;ieal  pnx-edures,  however,  that  are  not  al)Sohitely 
necessary  are  ohjcetionahle,  and  a  remote  possihility  even  of  an  accident 
of  tlie  kind  to  which  reference  has  been  made — viz.  ruj)ture  of  tlie  tube 
— sn<i;<;ests  that  these  applications  he  made  no  more  frecpientlv  than  will 
suffice  to  accomplish  <»ur  ohject.  I  think  it  ]»roper,  therefore,  to  sav 
that  a  strent^th  of  current  just  sufficient  to  destroy  the  fo'tal  life  is  it 
all  prohahility  capai)le  of  doing  it  at  once,  and  that  all  suhsecjuent 
efforts  serve  only  the  purpose  of  hastening  the  process  of  absorption. 

Ajiplications  that  are  made  solely  for  this  j)nrpose  eaiuiot  be  at  all 
objecti«Mial)le,  as  the  galvanic  cnrrent  without  interruption  is  the  kind 
to  be  used.  A  most  important  point  in  tlie  consideration  of  this  opera- 
tion is  its  simplicity  as  well  as  its  certainty.  I  find  the  idea  ver\-  widely 
prevailing  that  the  operation  is  purely  electrolytic,  necessitating  the 
introduction  of  needles  into  the  foetal  nest.  Happily,  such  is  not  the 
case,  for  any  such  procedure  might  itself  be  attended  with  danger,  and 
certainly  with  considerable  pain.  The  negative  electrode  consists  of  a 
metal  ball,  and  is  applied  to,  and  not  into,  the  tumor. 

From  its  greater  power  of  overcoming  resistance,  as  well  as  other 
physical  and  physiological  reasons,  it  will  seem  that  galvanism  ought 
to  be  preferable  to  other  forms  of  electricity  in  this  condition.  Fara- 
dism  has,  however,  been  used  with  success,  although  in  every  one  of 
my  own  cases  galvanism  has  been  the  sole  reliance.  The  galvanic  cur- 
rent LS  more  certain  in  its  action  and  its  effects  are  felt  deeper,  Avhile 
its  influence  on  the  process  of  absorption  is  of  course  far  greater  than 
that  of  farad  ism. 

In  any  case  of  tubal  pregnancy — and  especially  in  those  advanced 
conditions  ^diere  the  tube  is  greatly  distended  and  there  is  danger  of 
spontaneous  rupture — the  possibility  of  hastening  the  catastrophe  in 
the  attempt  to  destroy  the  life  of  the  foetus  should  never  be  lost  sight 
of.  The  tubes  themselves  are  but  slightly  supplied  with  muscular 
fibre,  and  the  danger  would  more  especially  arise  from  the  powerful 
compression  that  is  liable  to  be  exerted  by  the  abdominal  muscles,  and 
the  effort  should  be  so  to  diffuse  the  current  proceeding  from  the  exter- 
nal pole  as  to  produce  the  least  mechanical  effect  possible. 


MENSTRUATION,  AND  ITS  DISORDERS. 


By  W.   gill  WYLIE,  M.  D., 

New  Yoke. 


Menstruation,  when  normal,  could  be  better  described  by  a  physi- 
ologist, but  some  knowledge  of  it  is  as  essential  to  the  gynecologist  as 
the  knowledge  of  the  anatomy  of  the  generative  organs.  We  will 
not  attempt  to  go  fully  into  the  physiology  of  the  subject. 

In  healthy,  well-developed  women  between  the  ages  of  fourteen  and 
forty-four  menstruation  occurs  once  a  month,  except  during  pregnancy 
and  lactation.  It  usually  begins  in  temperate  climates  at  the  age  of 
thirteen  to  fifteen,  but  in  many  instances  much  earlier,  and  often  not 
till  sixteen  years  or  later.  In  warm  climates  it  begins  much  earlier, 
and  in  cold  climates  later.  It  may  be  delayed  by  serious  illness,  such 
as  ansemia,  etc.,  or  it  may  be  hastened  by  an  indoor  and  indolent  life, 
and  on  this  account  it  comes  earlier  in  those  brought  up  in  large  cities. 

Just  previous  to  the  first  menstruation  a  girl  shows  marked  indica- 
tion of  rapid  development.  Her  breasts  enlarge,  hair  grows  on  the 
mons  Veneris,  her  figure  fills  out,  and  her  manner  becomes  shy  and 
retiring.  As  a  rule,  menstruation  is  preceded  by  a  feeling  of  weight  in 
the  pelvis  and  slight  fulness  of  the  breasts.  Not  infrequently  there  is 
some  backache,  but  in  many  instances  the  first  conscious  indication  is  a 
flow  of  blood. 

The  time  of  the  flow  is  from  two  to  eight  days.  If  less  than  t^vo  or 
more  than  eight,  it  usually  indicates  either  local  or  general  disease. 
The  amount  of  flow  is  estimated  to  be  from  two  to  nine  ounces.  If 
less  than  five  or  six  ordinary  napkins  or  more  than  eighteen  are  pretty 
well  saturated,  then  the  amount  may  be  considered  abnormal.  The 
periodicity  is  very  variable :  now  and  then  we  will  meet  a  woman  who 
menstruates  on  or  about  the  same  day  of  each  month.  More  frequently 
it  returns  every  twenty-eight  days,  but  not  infrequently  it  occurs  every 
three  weeks.  In  most  cases  it  varies  slightly.  Usually  for  several 
hours  it  is  slight  in  quaiitity,  and  may  be  light  in  color ;  on  the  second 
or  third  day  it  is  usually  at  its  height  and  the  flow  is  dark,  and  unless 
very  free  it  will  not  coagulate  on  account  of  admixture  with  the  vaginal 
secretions.     After  the  third  or  fourth  day  it  ceases  gradually. 

408 


MEySTIiUATfOX,   A.\I>   ITS  DfSnRDFnS.  409 

Until  Bischoir  advanced  and  l*lli■l^(•l•  clahoi'atcd  and  dcvclojx'd  the 
tlieory  of  ovnlation  and  ovarian  ii-i-ilatinii  as  the  cause  of  menstruation, 
it  wiLs  tlic  belief  tiiat  (lie  nicnstnial  hlmul  was  accuniulaUid  to  snj)j)lv 
the  fetus,  and  was  thrown  oil'  as  noxious  niatei'ial  unless  the  woman 
heeame  pret^iiant.  For  many  yeai's  and  until  very  recently  ovulation 
has  been  considered  the  startint:;-|)oint  oi"  menstruation,  and  Prtii<:;er's 
tlieory  has  been  the  acce|)ted  doctrine.  But  lately,  since  UKUistruation 
luus  been  f  nuid  to  continue  with  re<i;ularity  in  many  ciuses  after  com- 
plete removal  of  both  ovaries,  other  views  are  assumiiifr  more  promi- 
nence. One  of  the  most  striking  is  that  of  Williams's  des(|namation 
theory,  wherein  he  claims  that  the  lining  membrane  down  to  the  mus- 
cles is  thrown  oif  with  each  menstruation. 

The  writings  and  investigations  by  Kundrat  and  Engelmann  attracted 
much  attention.  They  claim  that  only  the  superficial  layer  undergoes 
degeneration  and  is  thrown  oif.  Instead  of  examining  the  uterus  after 
death,  Moricke  curetted  the  uterus  of  living  women  during  menstrua- 
tion, and  on  examination  of  his  scrapings  claims  that  no  part  of  the 
lining  membrane  is  thrown  off. 

Leopold  thinks  that  the  bleeding  is  explained  by  the  anatomical 
arrangement  of  the  blood-vessels  of  the  endometrium.  He  does  show 
that  the  arterioles  supplying  the  capillaries  are  relatively  larger  and 
more  numerous  than  the  veins  that  carry  off  the  blood ;  and  from  this 
he  claims  that  when  there  is  a  sudden  afflux  of  blood  to  the  uterus 
the  capillaries  will  bleed,  because  they  are  subject  to  great  pressure, 
as  the  veins  cannot  carry  off  the  blood  as  fast  as  it  is  supplied. 
He  denies  that  there  is  fatty  degeneration  of  the  superficial  or  any 
other  layer,  and  says  that  the  bleeding  is  due  to  rupture  of  the 
capillaries. 

Lawson  Tait  now  claims  that  it  is  not  the  ovaries,  but  the  Fallopian 
tubes,  that  influence  menstruation — that  menstruation  is  induced  by  the 
active  movements  of  the  tubes  to  grasp  the  ovaries.  But  women  some- 
times menstruate  regularly  when  both  tubes  and  both  ovaries  have  been 
removed.  I  know  one  who  has  missed  not  more  than  two  menstrua- 
tions in  tw^o  years  and  a  half,  although  I  have  both  of  her  tubes  and 
ovaries  in  a  jar. 

Lowcnthal  ^  has  come  out  with  a  new  theory — viz.  "  A  Graafian 
follicle  ruptures  and  liberates  a  mature  ovum,  Avhich,  having  passed 
through  the  tube  into  the  uterus,  imbeds  itself  in  the  mucous  mem- 
brane ;  its  presence  sets  up  hyj^erplasia  and  forms  the  menstrual 
decidua.  If  this  ovum  is  impregnated,  the  menstrual  decidua  develops 
into  the  decidua  of  pregnancy ;  but  if  it  is  not  fertilized,  after  a  time 
it  perishes,  and  by  its  death  causes  the  disintegration  of  the  menstrual 
decidua,  and  thus  menstruation  is  induced."     This  may  occur,  but  it 

^  Archiv  fur  Gynafc,  Bd.  xxiv.  Hft.  2,  and  Bd.  xxvi.  Hft.  1. 


410  MENSTRUATION,  AND  ITS  DISORDERS. 

does  not  explain  menstruation  when  there  are  no  ovaries  to  supply  the 
ovum,  as  in  those  numerous  cases  where  both  tubes  are  occluded  by 
imflammatory  adhesions. 

In  the  American  Journal  of  Obstetrics  (1885,  vol.  xviii.  Nos.  2,  3, 
4,  5,  and  6)  Dr.  Mary  Putnam-Jacobi  elaborates  the  theory — "  First, 
that  the  essential  and  efficient  cause  of  the  menstrual  hemorrhage  lies 
in  the  accumiilation  of  blood  in  the  periuterine  and  utero-ovarian 
sinuses.  Second,  that  this  accumulation  does  not  constitute  a  conges- 
tion  But  that  the  immediate  cause  of  the   determination  of 

blood  to  the  reproductive  organs  is  the  gradual  enlargement  by  growth 
of  the  venous  reservoirs  destined  to  contain  it."  She  explains  the 
"  mechanism  by  which  the  material  for  reproductive  nutrition  is  evacu- 
ated." "  When  fecundation  has  not  occurred,  the  growing  endomet- 
rium, arrived  at  a  certain  point  of  development,  is  then  arrested  by 
the  non-expansion  of  the  uterine  cavity.  The  opposing  surfaces  of  the 
endometrium  touch,  press  against  each  other ;  the  vitality  of  the  sur- 
face epithelium  is  impaired ;  it  exfoliates,  laying  bare  the  surface  capil- 
lary loops,  which  break  at  some  point,  so  that  capillary  oozing  begins," 
etc.,  etc.  She  also  gives  an  explanation  of  the  "  mechanism  by  which 
hemorrhage  is  averted  after  fecundation,"  and  explains  "  the  individual 
variations  in  the  subjective  and  objective  phenomena  of  the  menstrual 
cycle  and  of  early  pregnancy." 

These  views,  as  given  by  Dr.  Jacobi,  are  exceedingly  interesting  and 
in  many  respects  new,  and  many  of  the  statements  are  so  rational  that 
they  must  be  accepted ;  but  the  very  completeness  of  it  impresses  one 
with  the  fact  that  as  yet  it  is  theoretical. 

Although  the  generative  organs  are  essential  to  reproduction,  they 
are  not  essential  to  the  individual  and  are  not  necessarily  used.  Disuse 
in  organic  life  means  in  time  atrophy  and  death.  Therefore,  menstrua- 
tion may  be  intended  to  take  the  place  of  the  free  exercise  of  the  func- 
tions of  these  organs,  and  thus  compensate  for  the  restraint  and  disuse 
so  much  and  so  necessarily  practised  by  civilized  races.  It  seems  to 
regenerate  a  part  at  least  of  the  uterus,  and  keep  it  in  proper  condition 
to  receive  and  nourish  the  ovum  when  impregnated. 

In  treating  uterine  diseases  it  is  important  to  recognize  the  fact  that 
for  several  davs  before  and  durins;  menstruation  the  uterus  is  somewhat 
enlarged,  and  the  lining  membrane  of  the  uterus  may  be  injured  or 
menstruation  disturbed  by  the  use  of  sounds  or  any  direct  applications 
— that,  as  a  nile,  interuterine  treatment  or  operative  procedures  should 
not  be  made  for  at  least  one  week  previous  to  menstruation,  nor  sooner 
than  three  or  four  clays  after  it  has  ceased. 

Disorders  of  menstruation  cannot  properly  be  classed  as  diseases,  for 
any  one  of  the  disorders  of  menstruation  may  be  one  of  the  symptoms 
of  several  different  diseases.     On  this  account  we  cannot  be  expected  to 


AMi:s()i:nu(i:.[.  411 

fjo  too   iiuu'h   into  details  of  (rcatiiiciit,  etc.,  as   iiiiK-li  of  it  \voiil<l  he  a 
r('|)('tiliou  of  that   i^'ivcii    l)y   tliosc  wfitiii;^-  on   the  dillrrciit   (liscascs. 

Amenorrhcea. 

Tlic  word  "  aiiuMiorrlid'a "  is  \\^vi\  to  indicate  suppression  or  cessa- 
tion ot"  tlie  menses  between  the  aj^e  of  pnberty  and  the  nienopanse. 
Altht)ni2,h  nienstrnation  may  oecur  during  pregnancy  or  hictation  with- 
out necessarily  indicating  serious  disease,  amenorrJKea  nuist  he  consid- 
ered normal  during  pregnancy  and  lactation,  and  before  puberty  and 
after  forty  years  of  age. 

Amenorrhcea  may  be  caused  in  two  ways  : 

1st,  it  may  be  due  to  the  debilitating  influence  of  some  constitutional 
disease  or  acute  general  disease. 

2d,  it  may  be  due  to  local  disease  or  to  imperfect  development  of  the 
generative  organs,  or  to  atrophy  of  one  or  more  of  these. 

During  the  active  stage  of,  and  convalescence  from,  serious  debilitating 
diseases,  such  as  the  essential  fevers,  phthisis,  etc.,  amcnorrhoea  is  to  be 
expected  and  is  desirable,  and,  instead  of  being  an  indication  of  local 
disease,  shows  that  there  is  nothing  about  the  generative  organs  which 
would  induce  hemorrhage,  that  might  lessen  the  chance  of  the  patient's 
recovery. 

In  chlorosis  and  anremia  amenorrhcea  is  especially  desirable,  and 
when  menstruation  exists  with  well-marked  ansemia  it  indicates  that 
there  may  be  an  abnormal  state  of  the  lining  membrane  of  the  uterus ; 
and  it  may  be  as  important  to  treat  this  condition,  and  thus  induce 
amenorrhcea,  as  it  would  be  to  stop  a  very  much  more  violent  hemor- 
rhage occurring  in  one  whose  general  condition  is  good. 

Five  years  ago  a  large,  handsome  Avoman,  about  forty-two  vears  old, 
came  to  me  for  treatment.  She  had  the  characteristic  skin  of  chronic 
anaemia,  with  puffed  lower  eyelids,  swelling  above  clavicles,  swollen 
feet,  etc. ;  was  always  tired  and  much  dej^ressed.  She  had  a  dragging 
pain  in  her  back,  etc.  On  physical  examination  I  found  a  large  retro- 
verted  and  retroflexed  uterus.  She  said  that  she  had  been  treated  for 
two  years  by  two  of  our  most  prominent  specialists,  who  had  used  ]ies- 
saries,  iodine,  hot  water,  etc.  Her  menstruation  was  pretty  regular, 
and  the  amount  lost  was  not  more  than  a  vigorous,  healthy  woman 
should  lose ;  but  I  concluded  that,  taking  into  consideration  her  gen- 
eral condition,  if  the  uterus  was  normal  she  should  have  amenorrlm^a. 
I  did  not  think  the  displacement  alone  accounted  for  the  menstruation. 
I  dilated  the  cervix,  and  with  a  Sims  curette  succeeded  in  removing  about 
a  tablcs]ioonful  of  fungus  granulations,  and  at  once  established  amcnor- 
rhrea,  and  after  a  few  months  improved  and  finally  cured  her  ansemia, 
and  all   indications  of  local   disease  disap})eared.     Since  then  I  have 


412  MENSTRUATION,  AND  ITS  DISORDERS. 

treated  other  cases  of  chlorosis  by  giving  treatment  to  bring  about 
amenorrhoea  when  the  general  health  indicated  it.  When  amenorrhcea 
is  due  to  ansemia  or  any  other  disease,  menstruation  usually  returns 
when  the  disease  causing  the  debility  is  cured ;  but  when  the  disease 
occurs  during  the  period  of  development,  say  from  ten  to  sixteen  years 
of  age,  if  the  disease  is  prolonged  and  greatly  reduces  the  vital  force, 
develoj)ment  of  the  generative  organs  will  be  checked,  and  the  final 
result  may  be  a  state  of  imperfect  development  of  the  generative  organs, 
which  not  only  unfits  them  for  performing  their  functions  normally, 
but  renders  them  an  easy  prey  to  disease.  Thus,  amenorrhoea  caused 
by  general  debility  may  exist  after  the  patient's  general  health  has  been 
fully  restored.  When  it  does  exist  after  the  general  health  is  restored, 
local  treatment  should  be  resorted  to,  to  prevent  further  degeneration 
and  atrophy,  and  if  possible  to  stimulate  the  uterus  and  adnexa  to  com- 
plete development.  When  we  find  amenorrhoea  in  connection  with  a 
small,  imperfectly  developed  hypersesthetic  uterus,  or  a  small  uterus  asso- 
ciated with  cystic  degeneration  of  the  ovaries  or  catarrhal  disease  of  the 
Fallopian  tubes,  we  must  trace  back  the  history  with  great  care  to  be 
able  to  determine  whether  the  imperfect  development  is  due  to  congeni- 
tal influences  or  to  the  direct  influence  of  some  debilitating  disease,  im- 
perfect nutrition,  or  bad  hygienic  conditions  acting  during  the  period 
of  development  of  the  generative  organs,  Amenorrhoea  may  be  caused 
by  superinvolution  of  the  uterus,  or  atrophy  of  the  tubes  and  ovaries 
the  result  of  extensive  or  destructive  inflammatory  local  disease.  Dur- 
ing the  acute  stages  of  uterine  and  periuterine  inflammation  menstrua- 
tion may  be  excessive,  but  when  contraction  of  adhesions  over  the  tubes 
and  ovaries  takes  place,  or  when  fatty  degeneration  and  cystic  degenera- 
tion take  place  in  the  uterine  tissue,  scanty  menstruation  is  the  rule, 
except  when  fungous  granulations  line  the  ^iterine  canal. 

It  is  a  well-established  fact  that  extreme  mental  emotion  in  many 
women,  such  as  fright,  anxiety,  grief,  etc.,  may  for  a  time  suppress  men- 
struation. Women  who  for  good  reasons  have  great  anxiety  about  the 
appearance  of  "their  menstruation  may  cause  temporary  suppression  by 
the  nervously  anxious  state  they  get  into  when  it  is  due. 

It  would  seem  that  some  women  are  liable  to  acute  catarrhal  disease 
of  the  uterus  in  the  same  way  as  they  are  to  catarrh  of  nose  and  throat, 
and  exposure  to  cold  near  the  time  of  the  menses  may  cause  suppres- 
sion. But,  as  a  rule,  these  are  only  temporary  in  their  eflect,  and  are 
not  so  serious  as  the  amenorrhoea  now  so  very  common  in  young 
women  who  are  urged  on  in  intellectual  studies,  in  addition  to  an 
indoor  life  and  other  bad  hygienic  influence,  during  the  period  of  the 
active  development  of  the  generative  organs.  They  thus  acquire  the 
habit  of  using  up  their  vital  force,  so  as  to  delay  or  render  very  imper- 
fect the  development  of  the  generative  organs.     These  organs  are  the 


AMEXORRHCEA.  413 

last  to  (l('V('I(t|),  ami  imt  liriiij;'  cssciilial  t<t  life  nor  to  mental  or  manual 
work,  tlu'V  aro  the  (irst  to  fail.  ( )nc  ol"  tlic  first  indications  of"  tliis 
serious  troiil)l('  is  <l('!av  in  the  coininLT  of  tlic  menses  or  suppression 
after  liavin;^;  l)e!j,un.  In  tnatint::  ol"  I  )y-nienorrli<i'a  1  will  refer  aj^ain 
to  this  important  suhjeet,  for  I  think  that  the  im|)erf"eet  development 
brou^iht  about  in  this  way  is  the  essential  cause,  not  only  of  many  eases 
of  ainenorrluea  and  dysmcnorrhoea,  i>ut  also  explaias  why  so  many 
aj)parently  healthy  women  have  uterine  disease  and  why  the  cervix 
is  so  freipiently  torn,  ete. 

Great  care  must  be  taken  to  diagnose  pregnancy  as  a  cause  of  amenor- 
rhani,  and  where  there  is  doubt  time  alone  Mill  enable  one  to  be  sure 
of  a  diagnosis. 

With  extra-uterine  pregnancy  amenorrhoca  or  scanty  menstruation 
exists,  and  yet  the  uterus  fails  to  enlarge  as  it  would  do  in  normal 
pregnancy.  Great  changes  of  the  mode  of  living,  such  as  a  sea-vo}'age, 
may  for  a  time  cause  amenorrhcea. 

Scanty  Jlen.sfruafion. — Almost  all  that  has  been  said  about  amen- 
orrhcea may  be  said  about  scanty  menstruation.  Very  much  the 
same  causes  would  induce  it,  and  its  treatment  should  be  very  sim- 
ilar. 

Amenorrhcea  may  also  be  due  to  absence  of  the  uterus  or  the  ovaries 
and  tubes  when  removed  by  operation  or  congenitally  absent.  In  con- 
genital absence  of  the  vagina,  or  in  complete  occlusion  or  atresia  of  the 
cervix  or  vagina,  the  menses  may  be  retained  and  cause  the  accumula- 
tion of  a  large  amount  of  tarry  mucus  and  blood  in  a  pouch  formed 
by  the  upper  part  of  the  vagina  or  the  uterine  cavits*.  These  mav  be 
mistaken  for  amenorrhcea,  but  can  hardly  be  classed  as  amenorrhcea. 
They  would  come  under  the  head  of  imperfect  development  or  disease 
of  the  cervix  and  vagina. 

Treatment. — Since  the  old  idea  of  the  noxious  influence  of  retained 
menstrual  blood  has  been  given  up  and  the  ovulation  theort"  accepted, 
emmenagogues  have  not  been  very  much  used. 

Practically,  little  good  is  done  by  the  use  of  medicines  in  amenor- 
rhcea, except  as  they  may  be  made  to  improve  the  general  health  of  the 
patient.  Amenorrhcea  brought  about  by  debility  due  to  general  and 
not  local  disease  does  not  require  special  treatment,  unless  the  amenor- 
rhcea continues  for  some  time  after  the  patient  has  fully  recovered  her 
general  health. 

In  anaemic  and  chlorotic  subjects  iron  in  suitable  forms  will  often 
cause  menstruation  to  appear,  but  this  may  be  by  improving  the  con- 
dition of  the  blood  rather  than  by  specific  action. 

Aloes  in  cases  of  suppression  of  the  menses,  if  used  at  or  near  the 
time  that  menstruation  is  due,  may  bring  it  on,  but  it  probablv  acts  by 
irritating  the  intestines  and  thus  causing  pelvic  congestion,  and  not  by 


414  MENSTRUATION,  AND  ITS  DISORD EBS. 

any  specific  action.  Other  medicines,  such  as  potassium  permanganate, 
binoxide  of  manganese,  oil  of  savine,  mustard,  etc.,  are  used  as  emmen- 
agogues,  but  their  usefulness  is  very  doubtful. 

The  application  of  heat  by  means  of  hot  baths  to  the  feet  or  hips 
may  be  safely  used,  but  except  where  menstruation  is  about  due  they 
are  not  to  be  relied  upon. 

Local  treatment  is  chiefly  useful  in  cases  of  imperfect  development, 
especially  where  amenorrhoea  occurs  during  the  period  of  development. 

At  the  same  time  that  an  eifort  is  being  made  to  improve  the  general 
health  of  the  patient  stimulating  applications  may  be  made  to  the 
uterus  and  the  vagina.  Hot-water  vaginal  douches  of  half  a  gallon, 
given  at  105°  to  115°  F.,  with  the  patient  lying  on  her  back,  are  some- 
times efficient,  and  can  always  safely  be  made  supplemental  to  more 
active  local  treatment. 

As  a  stimulating  and  safe  application  to  improve  the  local  circulation 
of  the  pelvis  I  prefer  a  solution  of  one  part  of  boro-glyceride,  one  of 
alum,  and  fourteen  of  pure  glycerin,  to  be  applied  to  the  vagina  by 
means  of  firm  rolls  of  absorbent  cotton  from  one  and  a  half  to  two 
inches  long  and  from  one-half  to  one  inch  thick,  tied  with  a  string  at 
one  end  to  facilitate  removal,  thoroughly  saturated  with  the  solution, 
and  applied  twice  a  week,  each  application  remaining  twenty-four  or 
forty-eight  hours.  This  application  causes  a  profuse  watery  flow,  and 
keeps  up  a  very  active  pelvic  circulation,  and  after  a  few  weeks'  use 
improves  the  local  condition  and  stimulates  development.  If  there 
are  catarrhal  disease  and  more  or  less  contraction  and  atrophy  of  the 
endometrium  associated  with  amenorrhoea,  after  the  above  applica- 
tions have  softened  the  parts  and  rendered  the  uterus  freely  movable 
the  cervix  should  be  dilated  and  stimulating  interuterine  applica- 
tions made. 

Electricity  regularly  applied  to  the  cavity  of  the  uterus  and  over  the 
ovaries  seems  to  stimulate  development  in  some  cases. 

In  those  cases  of  suppression  where  ten  or  twenty  years  ago  leeches 
to  the  cervix,  bleeding  from  the  arm,  and  emmenagogues  were  given,  I 
usually  give  a  free  laxative  and  apply  the  boro-glyceride  and  alum- 
and-glycerin  pledgets,  and  order  hot-water  douches  and  baths,  and  an 
anodyne  if  needed.  In  a  few  days  both  the  general  and  the  local 
congestion  are  relieved. 

In  cases  of  amenorrhoea  where  there  are  symptoms  of  pregnancy 
or  reasons  to  suspect  it,  no  interuterine  examinations  or  active  treat- 
ment should  be  given,  as  a  matter  of  course,  but  simple  laxatives  and 
the  cotton  pledgets  saturated  with  boro-glyceride  and  alum-and-gly- 
cerin  mixture  to  relieve  congestion  will  do  no  harm.  They  soften 
the  parts  and  enable  one  to  make  a  more  certain  diagnosis. 


ji//;.voA'/;//.ir,7.i  .i.\7>  mi:ti:')i:/:iia<;ia.  410 

Vicarious  Menstruation. 

A"icari(»iis  incnstniation  may  occur  in  (•(Uiiicctioii  with  amciiDrrliu'a 
or  scanty  menstniation.  \\'cll-iiiari<ctl  cases  arc  rare.  Its  >i;^iiilicaiiec 
is  not  of"  ^rcat  liuporlaMcc.  It  intlicatcs  a  watery  and  poor  condition 
of  the  blood,  usually  associated  with  a  constitutional  tendency  to  l)lced, 
due  in  some  cases  to  a  lauity  sttitc  of  the  blood-vessels.  The  blood  may 
come  from  the  throat,  nose,  ji'ums,  breasts,  or  an  open  sore  or  wound, 
and  it  mav  show  itsi'lf  with  reji;nlarity  at  the  time  of  the  menses  or 
when  the  circulation  is  disturbed  on  account  of  the  menses  beinu-  .sup- 
pressed. 1  have  seen  it  to  a  slisi'ht  extent  occur  in  a  woman  in  whom 
at  the  autopsy  not  even  a  sign  of  the  uterus  or  vagina  could  be  Ibimd, 
althouo;h  two  ovaries  were  found — one  in  the  canal  of  the  round  lig- 
anient  of  the  right  side,  the  other  near  the  hilus  of  the  left  and  only 
kidney. 

I  now  have  under  treatment  a  patient  with  occlusion  of  the  vagina 
who  regularly  eacli  month  has  nose-bleed.  An  an?cmic  woman  nnder 
my  care,  the  mother  of  six  children,  when  pregnant  with  her  seventh 
child  menstruated  with  perfect  regularity  from  the  bladder  for  eight 
months.  Except  a  slight  catarrh  of  the  bladder  that  had  existed  pre- 
viously, and  now  exists  eighteen  months  after  the  birth  of  the  child,  no 
other  disease  has  been  made  out.  After  the  birth  of  the  child  she  had 
aracnorrho?a  for  sixteen  months.  The  flow  from  the  bladder  was  dark 
in  color  and  quite  free,  and  lasted  five  or  six  days. 

Unless  the  hemorrhage  is  such  as  to  cause  trouble  from  the  amount 
of  blood  lost,  special  treatment  is  not  usually  indicated.  Cure  the  cause 
of  the  amenorrhoea,  and  in  most  cases  the  vicarious  menstruation  will 
cease. 

Menorrhagia  and  Metrorrhagia. 

The  term  ''  menorrhagia  "  is  used  to  indicate  excessive  or  prolonged 
menstrual  flow,  while  "  metrorrhagia  "  is  uterine  hemorrhage  occurring 
independently  of  the  menses.  It  must  not  be  forgotten  that  the  amount 
of  blood  lost  by  different  women  at  menstruation  varies  very  greatly,  and 
the  length  of  normal  flow  and  intervals  between  the  menses  also  varies 
greatlv.  The  best  indication  of  its  being  abnormal  is  either  a  sudden 
change  in  the  usual  length  of  time  or  quantity  of  flow,  and  its  influence 
on  the  general  health  of  the  patient. 

Menorrhagia,  and  especially  metrorrhagia,  as  a  rule,  indicate  local 
disease  or  a  change  in  the  tissues  of  the  lining  membrane  of  the  uterus 
the  result  of  disease.  In  diseases  such  as  scorbutis,  chlorosis,  and  in 
some  women  variola,  rubeola,  typhus  fever,  malaria,  etc.,  where  the 
blood  is  changed  in  character,  there  will  be  an  increase  in  the  amount, 
and  especial Iv  in  lengthening  of  the  time,  of  the  menstrual  flow.     As 


416  MENSTRUATION,  AND  ITS  DISORDERS. 

has  already  been  pointed  out,  amenorrhoea  is  the  rule  under  such  con- 
ditions of  the  blood,  and  a  careful  investigation  will  often  disclose  a 
local  state  of  the  lining  membrane,  such  as  fungous  granulations,  which 
will  account  not  only  for  the  menorrhagia,  but  for  the  existence  of  men- 
struation at  all  under  such  conditions ;  and  when  the  local  disease  is 
removed  it  will  be  easier  to  cure  the  disease  affecting  the  general  health. 
Sometimes  menorrhagia  seems  to  be  due  to  disturbances  of  the  general 
circulation,  such  as  is  caused  by  stenosis  or  insufficiency  of  the  mitral 
valves,  emphysema,  the  pressure  of  a  large  tumor,  or  the  use  of  active 
vascular  stimulants,  such  as  quinine,  etc.  This  influence,  of  course, 
would  be  more  likely  to  affect  a  uterus  that  is  not  in  a  perfectly  normal 
state,  and  we  can  often  prevent  injurious  effects  by  correcting  what- 
ever local  disease  or  abnormal  condition  may  be  found. 

Therefore,  we  must  come  to  the  conclusion  that  bad  conditions  of  the 
blood  and  disturbances  to  the  general  circulation  seldom  cause  menor- 
rhagia as  long  as  the  generative  organs  are  normal,  and  very  rarely 
could  induce  metrorrhagia,  except  when  acting  on  an  abnormal  or  dis- 
eased local  condition.  Local  conditions  that  cause  menorrhagia  and 
metrorrhagia  may  be  divided  into  two  classes — those  due  to  abnormal 
conditions  of  the  adnexa  and  periuterine  tissues,  and  those  due  directly 
to  abnormal  conditions  or  disease  of  the  tissues  of  the  uterus.  The 
latter  is  by  far  the  more  important  of  the  two,  and  when  uterine  hem- 
orrhage becomes  greatly  prolonged  or  recurs  persistently  it  will  usually 
be  found  that  fungous  granulation  or  some  such  change  in  the  lining 
membrane  has  taken  place.  In  acute  inflammation  of  the  periuterine 
tissues  caused  by  salpingitis,  ovaritis,  etc.  there  may  be  either  menor- 
rhagia or  metrorrhagia ;  but  this  local  flow  often  gives  relief  to  the 
pain,  and  unless  excessive — as  it  seems  to  us  favorable  to  the  progress 
of  the  periuterine  disease — it  is  best  not  to  check  it.  This  flow,  which 
so  frequently  occurs  during  an  acute  attack  of  local  peritonitis,  will  not 
recur  with  the  next  menstruation,  and  by  waiting  long  enough  a  differ- 
ential diagnosis  can  easily  be  made.  Unless  the  hemorrhage  be  very 
profuse,  it  is  usually  better  to  wait  until  it  has  recurred  once  or  twice 
before  resorting  to  curetting. 

Myomatous  fibroma  and  other  tumors  of  the  uterus  rarely  cause 
hemorrhage  unless  they  are  so  situated  as  to  increase  or  change  the 
vascular  condition  of  the  lining  membrane  of  the  body  of  the  uterus. 
It  is  not  uncommon  to  find  enormous  subperitoneal  fibromata  attached 
to  a  small  uterus  which  does  not  bleed  excessively  at  any  time.  Even 
very  vascular  myomata  may  be  attached  at  or  below  the  vaginal  junc- 
tion and  lift  the  uterus  to  the  ensiform  cartilage,  and  yet  not  cause 
menorrhagia.  I  operated  on  such  a  case  not  long  since,  and  a  few 
months  ago  I  removed  a  fibroma  the  size  of  the  head  of  a  five-year- 
old  child,  distending  the  cavity  of  the  cervix,  which  had  elevated  the 


MhWojiJniM.iA  A.\i>  Mi:ri:<ini:iiA(;i.\.  417 

siiimII  :iii<l  linn  hndyortlir  iitciii>  l<i  llir  iiiiiLiliciis,  nml  \(|  ihcrc  iicvci" 
liad  l)ini  citlici'  iii('Miirrli:i<;ia  oi-  iiictrori'linviin,  imr  (iNsniciiorrlKr'a.     V\tv 
sonic  vcars  past,  iiisl('a<l  <»!"  resort iii<i'  to  Hater's  operation    for  removal 
<»t"  tlie  ovaries  or  jterloi-niiiiti    li\>tereetoni\   for  iiterin*-   lieniorrliatic,  I 
have   lirst    tried   tlie  elleet  of  enrettint;'  tlie  eavity  of  the  litems.      Tlie 
resiihs  have  heeii  so  satisfactory  and  histiii*;-  that  I  have  lost  tlie  chanec 
<if  |ierforiniiiu-  laparotomy  in  a  lar^'c  miiid)ei"  of  ease.-.      And   I  can  sav 
the  same  in  regard  to  those  eases  where  the  hemori'ha;^-e  appears  to  he 
due  to  ovaritis.      I    wonid  always  use  the  curette  in  such  eases,  oven 
thonii'h  the  evidence  of  Lirannlatioiis  were  iiex'cr  so  slight,  hefore  I'csort- 
iiiii'  to  laparotomy  lor  nterine  hcinori'liauc      Acute  inllammation  of  the 
litems  may  cause  snppression  of  the  incnsti'iiation,  and   usually  results 
in  irrcunlar  mcnstrnatioii ;  hnt  when,  as  it  (tften  is,  associated  with  sni)- 
involntion  after  lahor,  and  especially  aiter  abortions,  fiing:ons  granula- 
tions form,  and  in  inanv  cause  menorrhauia.      Some  such  chaiiiros  in 
the    vascular  con<lition  of  the    lininti'  membrane  of  the  body  of  the 
uterus    will  be    found    in    the    vast    majority  of  instances   to    be  the 
immediate    cause    of  both  raenorrhagia  and    metrorrhagia,  of  course 
excluding  cancer,  sarcoma,  large  polypi,  etc.     Subinvolution,  follicu- 
lar and   glandular   disease  of  the  cervix    associated   with    laceration, 
displacements,  etc.,   may  be  called  the  primary  cause ;  but  the  cases 
of  menorrhagia  and  metrorrhagia  associated  ^vith  or  follo\ving  these 
conditions  are  \ery  rare  that   do  not  cease  after  proper  preparatory 
treatment  and  cui-etting. 

Cancer  in  women  over  thirty-five  years  of  age  is  the  most  frequent 
cause  of  metrorrhagia,  and  on  account  of  the  importance  of  recogniz- 
ing this  disease  in  its  earlier  stages  it  is  the  duty  of  a  doctor  to  insist 
upon  a  local  examination,  as  being  the  only  certain  means  of  making 
a  diagnosis. 

The  menopause  has  been  commonly  credited  with  causing  both  men- 
orrhagia and  metrorrhagia,  both  by  doctors  and  patients,  but  I  have 
rarely  seen  a  well-marked  case  occurring  at  that  time  without  its  being 
due  to  some  well-defined  uterine  disease,  most  frequently  directly  caused 
by  either  fungous  granulations  or  cancerous  disease.  If  physicians  could 
be  generally  impressed  with  these  facts,  we  would  not  so  frequently  see 
cancer  of  the  cervix  advanced  to  a  hopeless  stage  before  an  examination 
is  deemed  necessary,  on  account  of  the  erroneous  belief  that  irregular 
uterine  hemorrhage  is  normal  at  the  menopause.  Retained  meml)ranes 
after  labor  and  abortions  not  only  may  induce  puerperal  hemorrhage, 
but  may  in  time  cause  morbid  growths,  such  as  fimgous  granulations, 
and  thus  induce  menorrhagia.  We  will  not  attempt  to  speak  more 
explicitly  of  hemorrhage  due  to  this  cause. 

Treatment. — In  describing  the  causes  of  menorrhagia  and  metror- 
rhagia the  treatment  has  been  indicate<l,  and  we  will  now  speak  chieflv 
Vol.  I.— 27 


418 


MENSTRUATION,   AND  ITS  BIS  ORDERS. 


of  the  special  treatment,  and  more  particularly  of  the  two  principal 
local  means  of  correcting  uterine  hemorrhage. 

Haemostatics  acting  through  the  general  system  on  the  uterus  are 
sometimes  useful  in  decreasing  the  flow,  but  are  rarely  curative  in  their 
action.  Ergot,  when  the  uterus  is  enlarged,  will  cause  uterine  contrac- 
tions, but  it  cannot  be  relied  upon  to  control  menorrhagia  or  metror- 
rhagia. A  fresh  preparation  of  cannabis  indica,  given  in  pretty  full 
doses  twice  a  day,  wdll  in  many  cases  control  or  lessen  the  flow  in 
menorrhagia.  Complete  rest  in  bed  also  diminishes  the  flow.  But  to 
cure  menorrhagia  or  metrorrhagia  local  treatment  must  be  given  in  the 
great  majority  of  cases.  The  tampon  as  generally  used  does  more  harm 
than  good.  In  the  first  place,  unless  it  is  properly  applied  by  an  expert 
it  rarely  stops  hemorrhage  of  consequence,  and  usually  merely  conceals 
it  for  a  time ;  secondly,  in  using  a  tampon,  and  leaving  it  in  place 
longer  than  is  necessary  to  cause  a  clot  to  form,  we  violate  one  of  the 
most  important  laws  of  good  surgery — namely,  obstructing  free  drain- 
age.    We  also  run  the  risk  of  forcing  irritating  and  perhaps  septic 


Fig.  173. 


Sims's  Curette.    There  are  three  sizes.    It  is  made  of  steel,  with  edges  sharp  enough  to  scrape^ 
hut  not  sharp  enough  to  cut  with. 

material  from  the  uterine  cavity  into  and  through  the  Fallopian  tubes 
into  the  peritoneum.  The  same  objections  hold  good  against  the  use 
of  tents,  especially  sponge  tents.  When  a  tampon  is  to  be  used  the 
cotton  pads  should  be  squeezed  out  in  a  solution  of  bichloride,  1  to 
5000,  and  well  sprinkled  with  iodoform  before  being  inserted.  A 
good  pair  of  Sims's  uterine  dilators,  when  properly  handled,  soon 
enable  one  to  dilate  the  cervix  uteri,  and  when  a  piece  of  retained 
placenta  or  fungous  granulations  are  effectually  removed  by  means 
of  a  Sims  curette,  any  bleeding  that  may  follow  can,  as  a  rule,  be 
controlled  by  the  use  of  hot  water  at  a  temperature  of  120°  F.,  fol- 
lowed by  ice- water,  either  injected  or  quickly  applied  by  small  sponges 
on  sponge-holders. 

It  is  better  to  keep  the  patient  on  the  table  for  half  an  hour  or 
longer  after  curetting,  so  as  to  prevent  hemorrhage,  than  to  insert  a 


D  YSMENORRHCEA .  419 

tainjxtii  I'or  the  purpose.  The  j;ynoe()lotj;i.st  who  cannot  use  Sims's 
steel  curette  witliout  seriously  iujuriiij;  the  uterus  is  not  skilful  enou;ih 
to  use  any  curette.  By  cleanliness  and  the  use  of  antisepti<-s  (he  onlv 
real   (lanii:er    in   its    ux — namely,   scpti<-    poisoning — is  re<Uice<l    to    a 

ininunn. 

Even  in  severe  uterine  lienionhage  after  abortion  it  is  best  to  at 
once  dilate  the  cervix  with  a  dilator,  and  remove  with  the  curette 
any  retained  nicnihrane,  and  avoid  the  use  of  either  sponjre  or  other 
tents  or  tanipi>ns. 

Dysmenorrhoea. 

The  term  "dysmenorrhoea"  is  generally  used  as  meaning  painful 
menstruation,  but  othei's  define  it  so  as  to  include  pain  just  before, 
during,  and  just  after  menstruation. 

There  is  but  little  doubt  that  for  at  least  one  week  before  the  men- 
strual flow  shows  itself  there  is  an  increase^  the  amount  of  blood  in 
the  pelvis,  and  there  is  good  reason  to  think  that  this  increase  of  vascular 
tension  in  and  about  the  uterus  gradually  grows  greater  up  to  the  time 
that  menstruation  begins.  Xow,  if  we  are  to  include  all  the  disturbance 
and  pain  caused  by  this  gradual  distension  of  the  pelvic  vessels,  and  the 
pain  that  occurs  with  the  flow  and  that  which  sometimes  occurs  when 
the  flow  is  more  or  less  suppressed,  in  our  description  of  dysmenorrhoea, 
there  would  be  little  to  distinguish  it  from  the  pain  of  pelvic  peritonitis, 
ovaritis,  etc.  It  seems  to  me  that  it  is  best  to  limit  the  use  of  the  word 
"dysmenorrhoea"  to  describe  the  difficulty  caused  by  the  flow  from  the 
time  it  begins  in  the  uterus — which  may  be  hours  before  it  shows  itself 
at  the  vulva — until  it  ceases.  To  get  a  clear  conception  of  dvsmenor- 
rhoea  it  is  important  to  recognize  the  fact  that  we  frequentlv  see  cases 
where  severe  pelvic  pains,  especially  pain  over  one  or  both  ovaries,  that 
has  gradually  grown  worse  for  several  days  previous  to  menstruation, 
subside  as  the  flow  begins,  and  disappear  when  it  is  Avell  established. 
It  is  plain  that  the  flow  relieves  the  vascular  tension,  and  thus  lessens 
the  pressure  on  the  sensitive  ovaries,  tubes,  or  periuterine  tissue ;  yet 
many  authors  describe  fully  what  they  call  "  ovarian  dysmenorrhoea." 

Ovarian  disease  often  complicates  menstruation,  and  when  menstrua- 
tion is  difficult  and  creates  such  an  irritation  as  to  increase  for  the  time 
the  actual  amount  of  blood  in  the  pelvis,  instead  of  lessening  it,  the 
ovarian  pain  may  be  intensifie<l ;  but  T  am  inclined  to  doubt  if  ovarian 
disease  ever  directly  causes  painful  menstruation.  Certain  diseases  of 
the  ovaries  may  bring  about  structural  changes  in  the  uterus,  and  dys- 
menorrhoea be  the  residt,  but  the  immediate  cause  of  the  dysmenorrhrea 
is  in  the  uterus.  Ovulation  occurring  in  a  diseased  ovar^'  or  in  one 
encased  in  inflammatory-  adhesions  may  take  place  at  the  same  time 
with  the  menstrual  flow,  and  thus  cause  pain ;  but  unless  it  can  be 


420  MENSTRUATION,  AND  ITS  DISORDERS. 

shown  that  the  menstrual  flow  causes  ovulation  this  pain  cannot  be 
fairly  termed  dysmenorrhoea.  There  is  some  reason  to  think  that  the 
Fallopian  tubes  may  be  active  at  or  about  the  time  of  menstruation. 
In  removing  the  appendages  for  disease  I  have  several  times  found  the 
fimbriee  spread  out  over  the  surface  of  the  ovary,  just  as  the  fingers 
would  be  when  one  picks  up  a  large  ball,  and  firmly  fixed  by  adhesions. 
Now,  under  what  conditions  this  takes  place  I  do  not  know,  and  we  do 
not  yet  know  what  the  normal  action  of  the  tubes  is  during  menstrua- 
tion, but  I  am  certain  that  we  often  find  marked  disease  of  the  tubes 
and  ovaries  fixed  by  adhesions  in  women  who  do  not  have  dysmenor- 
rhoea; on  the  contrary,  they  feel  better  at  that  time  than  at  others.  In 
quite  a  number  of  cases  I  have  succeeded  in  curing  the  dysmenorrhoea 
that  complicated  salpingitis  by  dilating  and  treating  the  uterine  canal 
before  operating  for  removal  of  the  tubes  and  ovaries.  In  three  well- 
marked  cases  I  failed  to  cure  the  dysmenorrhea  because  the  treatment 
caused  fresh  pelvic  peritonitis  and  cut  short  the  interuterine  treatment ; 
but  this  was  not  an  unlooked-for  result,  although  long  preparatory 
treatment  was  given  in  each  case  to  render  the  uterus  movable  and 
lessen  the  chance  of  disturbing  the  periuterine  tissues.  After  three 
years'  close  observation  of  many  cases,  during  which  time  I  have 
removed  the  tubes  and  ovaries  for  disease  thirty-seven  times,  I  have 
come  to  the  conclusion  that  the  change  that  takes  place  in  the  pelvic 
tissues  for  some  days  previous  to  menstruation  often  causes  increased 
pain  in  diseased  tubes  and  ovaries,  but  that,  except  in  those  cases  where 
other  causes  for  dysmenorrhoea  exist,  the  menstrual  flow  actually  gives 
relief,  especially  if  the  patient  is  in  bed.  It  is  true  that  in  well-marked 
cases  of  disease  of  the  uterine  appendages  the  patient  may  suffer  from 
dysmenorrhoea,  but  a  careful  investigation  of  these  cases  will  in  most 
instances  disclose  abnormal  conditions  about  the  uterus  that  will  account 
for  the  dysmenorrhoea. 

Just  before  and  during  menstruation  women  with  periuterine  disease 
may  have  increased  pelvic  pains  when  up  and  about,  and  especially 
when  standing,  but  these  are  due  to  the  influence  of  gravity  causing 
pelvic  congestion,  and  not  to  the  flow. 

Disease  of  the,  uterine  appendages  undoubtedly  often  complicates,  and 
is  frequently  associated  with,  dysmenorrhoea,  and  certain  destructive 
diseases  of  the  ovaries  and  tubes  may  in  time  cause  structural  changes 
in  the  uterus  that  may  result  in  dysmenorrhoea ;  but  I  doubt  if  dys- 
menorrhoea, properly  speaking,  can  be  called  ovarian  dysmenorrhoea. 

Most  of  the  attacks  of  pelvic  peritonitis  so  common  in,  and  so  cha- 
racteristic of,  salpingitis  occur  at  or  about  the  time  of  menstruation, 
and  very  frequently  complicate  dysmenorrhoea.  Hemorrhages  may 
form  haematoceles,  serous  effiision  due  to  local  peritonitis  take  place, 
and  other  causes  of  pain  may  complicate  menstruation,  but  these  are 


l)YsMi:s(n:i:iiii:A.  .121 

not  tliu'  It)  the  Miciistnial  flow  :  tlicy  mav  he  caused  hv  llic  <'liaii;j:('s  out- 
side of  tlie  uterus  wliieli  tenuiuale  in  menstruation. 

Ivrn)i,()(;v. — 'Piie  lluw  of  nieustniatidn  is  cau.-ed  Uyelianges  that  take 
place  in  the  liuiu;;-  inenihrane  of  the  utci'us,  and  when  |)ain  results  from 
this  How  its  cause  is  to  he  found  in  the  tissues  irritatetl  j)y  or  |)ressed 
upon   l)v  the  Mow. 

Kxciudiuij;  those  rare  eases  whei'e  there  is  disease  or  occlusion  or  com- 
plete atresia  of  the  vagina  or  an  imj)erforate  hymen  that  may  cause  |)ain 
by  obstruetini;  the  flow,  there  are  only  the  endumetrium  and  the  under- 
lying' uterine  walls  in  which  to  examine  for  obstruction  to  the  How. 
When  th(>  flow  is  ol)strncted  it  may  accumulate  in  the  uterus,  distend 
the  cavitv,  and  j)ress  upon  the  linint;-  meml)i'ane  or  muscular  wall,  and 
thus  cause  pain,  es[)ecially  if  these  are  diseased  ;  or  when  ohstructed  it 
may  accumulate  in  the  periuterine  tissues,  al)normally  distend  the 
blood-vessels,  an<l  thus  cause  pain,  especially  in  diseased  periuterine 
tissues  or  oriians ;  or  it  may  be  driven  into  and  through  the  tubes, 
e.speeially  if  diseased,  and  irritate  the  tissues  of  the  tubes  or  perito- 
neum, and  thus  cause  })ain  ;  l)ut  in  all  of  these  the  obstruetion  is  the 
essential,  and  therefore  the  real,  cause  of  the  dysmenorrhrea. 

We  know  that  many  tissues  when  normal  are  not  painful  A\hen 
pressed  u[)on,  but  that  when  diseased  or  wli(»n  they  have  been  changed 
by  disease,  especially  by  what  we  term  inflammatory  disease,  these  same 
tissues  become  exquisitely  sensitive  to  very  slight  pressure,  and  often 
become  incapable  of  performing  their  normal  functions  without  creat- 
ing pain  located  in  themselves  or  by  what  we  call  reflex  action  in  some 
other  tissue  or  organ. 

If  we  knew  definitely  the  physiological  processes  of  normal  menstru- 
ation, we  could  soon  determine  the  true  pathology  of  dysmenorrhoea ; 
but  since  our  knowledge  is  so  slight  and  the  views  of  the  best  inves- 
tigators are  so  conflicting,  we  are  obliged  to  rely  u])on  clinical  experi- 
ence to  guide  us.  My  experience  has  led  me  to  some  very  definite  con- 
clusions about  the  cause  of  dysmenorrhoea.  In  the  majority  of  instances 
I  think  it  is  caused  by  a  hyperaesthetic  condition  of  the  endometrium, 
especially  at  or  near  the  os  internum,  often  combined  with  more  or  less 
stenosis  or  induration  at  this  point — stenosis  due  to  degeneration,  con- 
traction and  atrophy,  the  result  of  imperfect  development  followed  by 
disease,  or  disease  followed  by  induration,  atrophy,  and  contraction. 
These  same  conditions,  in  all  probability,  render  abnormal  the  processes 
that  take  place  in  the  endometrium  previous  to  and  during  the  flow — 
may  cause  it  to  disintegrate  and  exfoliate  in  pieces,  and  add  to  the  pres- 
sure of  the  blood  or  cause  spasmodic  muscular  contractions,  etc.  The 
hypergesthesia  may  induce  spasmodic  uterine  contraction,  which  luay 
cause  the  pain  without  the  presence  of  any  special  induration  or  stenosis 
at  or  about  the  os  internum. 


422  MENSTRUATION,   AND  ITS  DISORDERS. 

Take  a  well-marked  case  of  dysmenorrlioea,  and  pass  a  large  sound, 
yet  one  that  may  be  passed  into  a  normal  uterus  without  causing  pain 
as  it  passes  the  os  internum :  it  causes  a  severe  aching  pain,  and  fre- 
quently the  patient  will  voluntarily  exclaim  that  it  causes  the  same  pain 
as  menstruation.  Even  in  those  who  have  only  slight  dysmenorrhoea 
very  little  pressure  with  the  blades  of  a  uterine  dilator  will  cause  the 
characteristic  pain. 

It  only  causes  confusion  to  classify  dysmenorrhoea  as  neuralgic, 
ovarian,  obstructive,  etc.  Clinically,  it  cannot  be  done.  It  is  true 
that  ovarian  and  other  diseased  tissues  about  the  pelvis  become  more 
painful  on  account  of  the  vascular  tension  in  the  pelvis  before  and  until 
menstruation  is  well  established ;  but  unless  there  are  abnormal  changes 
in  the  lining  membrane  or  decided  obstruction  to  the  flow  menstruation 
will  relieve  the  pain  caused  by  congestion  in  the  i^eriuterine  tissues.  In 
acute  inflammation  or  disease  of  the  uterus  itself,  unless  the  flow  is 
retarded  by  pressure  of  the  swelling,  menstruation  lessens  the  pain, 
and  the  pain  varies  inversely  wath  the  amount  of  the  flow. 

The  hypersesthetic  and  indurated  state  of  the  tissues  so  characteristic 
of  typical  cases  of  dysmenorrhoea  appears  to  be  an  abnormal  condition, 
the  result  of  imperfect  development  and  atrophy,  or  disease  followed  by 
atrophy,  rather  than  the  existence  of  an  acute  disease.  I  have  never 
been  able  to  determine  whether  fissures  about  the  os  internum  may 
not  sometimes  cause  \he  hypersesthesia  and  dysmenorrhoea. 

Many  of  the  worst  cases  of  dysmenorrhoea  occur  in  young  women 
during  the  period  of  development,  without  their  ever  having  had  any 
symptoms  of  local  disease,  unless  the  slight  leucorrhoea  which  may  be 
present  at  times  be  so  considered.  This  leucorrhoea  would  not  be  a 
symptom  of  anything  more  than  a  subacute  catarrhal  condition  of  the 
endometrium,  which  Avould  be  likely  to  occur  in  imperfectly  developed 
and  atrophying  tissues  ;  nor  would  we  expect  imperfectly  developed  and 
atrophying  tissues  to  either  resist  disease  or  go  through  an  elaborate 
change  every  month  normally.  Therefore,  anything  which  arrests  or 
renders  imperfect  the  development  of  the  generative  organs  may  indi- 
rectly cause  dysmenorrhoea  ;  or  any  disease  of  these  organs  that  results 
in  degeneration  and  local  atrophy  may  cause  dysmenorrhoea. 

Dysmenorrhoea  is  very  frequently  associated  with  a  bad  condition  of 
the  nervous  system — a  "  neuralgic  diathesis,"  if  you  wish  to  call  it  so ; 
but  this  is  no  certain  indication  that  the  neuralgic  diathesis  causes  the 
dysmenorrhoea.  It  is  more  than  likely  that  both  are  the  result  of  some 
constitutional  disease  or  of  imperfect  nutrition. 

Cystic  degeneration  of  the  ovaries  is  often  associated  with  dysmenor- 
rhoea, and  it  is  more  than  likely  that  a  disease  of  the  ovaries  resulting 
in  degeneration  and  atrophy  may  thus  cause  the  conditions  in  the  ute- 
rus which  induce  dysmenorrhoea ;   but  the  natural  result  of  atrophied 


X»  YSMESOliniHEA.  423 

ovaries,  iis  a  rulo,  is  ainenorrlKiia.  In  most  cases  it  is  piohalile  that 
the  saiiu'  iuHueiu-es  wliirh  cause  cystic  (lej^ciu  ration  and  atrophy  of 
the  ovaries  render  imperfect  the  development  of  the  uterus;  and 
this  residts  in  atrophy,  contraction,  and  hypcra'sthcsia  which  causes 
the  dysnicuorrh(ea. 

In  nulliparous  women  characteristic  cases  of  dysmenorriujea  are 
nearly  always  associated  \\'\\.\\  decided  anteflexion,  but  it  has  never 
been  satisfactorily  j)roven  that  the  flexion  is  ever  the  cause  of  the 
dysmenorrhoea.  That  a  man  feeble  from  sickness  bends  over  when 
he  walks  does  not  j)r()ve  that  the  pain  he  may  endure  or  his  loss  of 
strength  is  due  to  the  flexion  of  his  spine. 

Yeiu's  ago  I  abandoned  the  prevailing  belief  that  anteflexion  fre- 
quently causes  dysmenorrhoea  directly  by  mechanically  closing  the 
canal,  ^^'iu•n  the  flexion  is  extreme  it  may  to  some  extent  obstruct 
a  free  flow  from  the  uterus,  but  unless  there  is  associated  with  the 
flexion  a  hypersesthetic  state  of  the  lining  membrane,  and  this,  as  it 
nearly  always  is,  complicated  by  contraction  or  inability  to  expand, 
there  w'ill  be  no  dysmenorrhoea.  Dilate  the  cervix  and  cure  the  hyper- 
aesthesia,  and  the  dysmenorrhoea  disappears,  although  the  flexion 
remains.  It  may  be  said  that  when  you  dilate  the  cervix  you 
straighten  the  uterus,  and  it  is  this  that  cures  the  dysmenorrhoea  ;  l)ut 
the  answer  to  this  is  that  until  the  uterus  begins  to  develop  strength 
under  the  stimulating  influence  of  treatment  the  uterus  bends  on  itself 
as  soon  as  the  dilators  are  removed,  although  one  or  two  effectual  dila- 
tations may  completely  relieve  all  pain  at  menstruation.  Besides,  when 
a  stem  pessary  is  used  and  dysmenorrhoea  is  relieved  by  it,  the  uterus 
is  not  only  straightened,  but  the  cervix  is  dilated  and  a  decided  change 
brought  about  iu  the  lining  membrane  by  the  presence  of  the  pessary 
in  the  uterus. 

The  use  of  vaginal  anteflexion  pessaries  may  palliate  some  of  the 
symptoms  associated  with  dysmenorrhoea,  but  unless  the  hot-water 
douches  used  to  keep  the  pessaries  clean,  or  the  laxative  and  tonics 
given  to  improve  the  general  health  usually  prescribed  m  ith  the  use 
of  the  pessary,  stimulate  development,  the  pessary  will  have  but  little 
influence  on  the  dysmenorrhoea  associated  with  the  flexion. 

Extreme  retroflexion  when  the  uterus  is  forced  down  against  the 
sacrum  between  the  utero-sacral  ligaments  may,  by  interfering  with  the 
uterine  circulation,  obstruct  the  flow  and  cause  pain  with  menstruation. 
Extreme  stenosis  of  the  os  externum  may  obstruct  the  flow  and  cause 
dysmenorrhoea.  This  may  be  due  to  congenital  influences  or  be  the 
result  of  disease,  or  be  due  to  cicatrization  from  the  use  of  caustics, 
galvano-cauteries,  etc. 

If  we  are  right  when  we  say  that  dysmenorrhoea  is  chiefly  due  to  a 
hyperjBsthetic  condition  of  the  membrane  lining  the  body  of  the  uterus, 


424  MENSTRUATION,   AND  ITS  DISORDERS. 

associated  with  a  contracted  or  inelastic  and  irritable  state  of  the  tissues 
at  or  about  the  os  internum,  and  that  in  most  cases  this  condition  is 
brought  about  by  incomplete  or  arrested  development  of  the  generative 
organs,  followed  by  atrophy  or  by  degeneration  the  effect  of  local 
disease  that  results  in  degeneration  and  atrophy,  not  only  are  the 
indications  for  treatment  of  dysmenorrhoea  made  plain,  but  also  the 
very  great  importance  of  preventing  the  further  advance  of  the  serious 
condition  connected  with  it,  of  which  the  dysmenorrhoea  is  one  of  the 
first  undoubted  symptoms. 

It  is  a  well-recognized  fact  that  dysmenorrhoea  is  much  more  common 
among  highly-educated  and  well-to-do  classes  than  among  the  laboring 
classes.  This  is  probably  due  to  two  causes  :  1st.  Among  the  rich  the 
law  of  survival  of  the  fittest  is  interfered  with  ;  that  is,  among  the  poor 
the  feeble  and  sickly  children  die  in  infancy  or  early  youth,  while  many 
children  of  the  rich  with  inherited  tendencies  to  disease  are  by  the 
better  care  that  they  receive  enabled  to  reach  puberty.  2d.  As  the 
children  of  the  rich  approach  puberty  the  girls  are  kept  indoors, 
deprived  of  fresh  air  and  sunlight,  and  by  custom  compelled  to  lead 
physically  passive  and  indolent  lives  as  compared  with  the  poor  or 
working  class.  Besides  being  enfeebled  by  bad  hygienic  environments, 
they  are  compelled  to  expend  all  available  force  in  intellectual  work  at 
a  time  when  the  generative  organs  should  be  developed.  Even  where 
a  good  constitution  is  inherited,  and  sufficient  food,  exercise,  and  sun- 
light are  allowed  to  fairly  well  develop  the  muscular  system,  if  emotional 
and  intellectual  work  is  forced  upon  them  during  the  period  that  the 
generative  organs  should  be  developed  or  allowed  force  to  develop,  they 
will  be  likely  to  suffer  from  dysmenorrhoea  due  to  imperfect  develop- 
ment of  the  generative  organs.  Numerous  examples  of  this  class  can 
be  found  among  the  scholars  of  our  normal  schools,  for  it  is  here  that 
the  brightest  graduates  of  our  high  schools  go,  their  successes,  prizes, 
etc.  being  additional  incentives  to  keep  up  the  intellectual  strain,  and 
thereby  longer  delay  the  full  development  of  the  generative  organs. 
In  this  country  intellectual  education  is  more  general  among  women 
than  in  any  other,  and  the  influence  of  imperfectly  developed  uteri  in 
causing  laceration  of  the  cervix,  etc.  may  partly  explain  why  so  many 
women,  comparatively  speaking,  seem  to  suffer  with  uterine  disease. 

The  generative  organs  are  not  essential  to  the  life  of  the  individual, 
and,  being  last  to  develop,  naturally  may  be  the  first  to  suffer  if  the 
vital  forces  are  insufficient  or  if  they  are  forcibly  absorbed  by  brain- 
work.  It  would  seem  that  a  certain  amount  of  surplus  of  strength 
and  force  is  requisite  for  the  perfect  development  of  the  generative 
organs.  If  women  are  to  avoid  diseases  of  the  generative  organs  and 
are  to  bear  children,  their  vital  forces  should  not  be  exhausted  nor 
forcibly  diverted  by  emotional  or  intellectual  work  during  the  period 


that  tlu'v  aiv  cliaiiijiii^'  I'roiii  <;irlli<i()(l  t<>  wtmiaiihoud.  Dm'iiit,^  tlic 
jH'ritxl  (if  (lc'V('l(>|)iiu'iit,  tVtiiii  ten  to  seventeen  yeai's  oi"  atic,  ;:(i(m1  HmmI, 
free  open-air  exei'cise,  and  sinilii;lit  are  e>|ieeiall\'  needed,  and  lr<'edoni 
from  emotional  excitement,  eare,  and  anxiety  is  desiralile;  and  all 
intelleetnal  elTort  that  is  lahorions  or  al)sorl)in<;'  shonld  and  can  he 
deterred  nntil  Ihll  development  of  the  u'enerative  or<2;ans  has  heen 
secured. 

To  ]>rcvent  the  etVeets  of  either  ii'eneral  or  local  disease  resnltinj;-  in 
dysmenorrluea  it  is  important  not  oidy  to  enre  the  disease,  hnt  also  to 
not  too  Ion*;-  delay  liivin^-  stinudatinu;  local  treatment  when  indicated 
bv  the  eontimumee  of  amenorrluea,  in  order  to  prevent  degeneratioa 
and  atrophy. 

Tin:A'r>[K\T. — To  relieve  the  pain  caused  by  disease  of  the  tubes, 
ovaries,  or  periuterine  tissues,  so  far  as  menstruation  intluenees  it,  the 
best  thing  to  do  is  to  increase  the  flow  rather  than  stop  it.  0[)ium  not 
only  dulls  the  pain,  but  at  the  same  time  seems  to  relax  the  local  con- 
gestion, and  thus  increases  or  equalizes  the  flow.  Its  influence  in  this 
respect  on  the  congestion  due  to  acute  local  inflammation  of  the  uterus 
itself  is  still  more  marked.  Local  treatment  to  the  uterine  cavity 
should  not  be  undertaken  in  these  complicated  cases  until  they  have 
been  rendered  subacute  and  the  uterus  made  movable  by  the  prolonged 
use  of  simple  vaginal  application,  which  will  improve  the  circulation 
of  the  pelvis,  and  thus  cause  the  absorption  of  most  of  the  products  of 
inflammation  and  render  pliable  the  peritoneal  adhesion  that  may  be 
present.  When  the  uterine  sound  is  used,  it  will  show  in  Avell-marked 
cases  of  dysmenorrhoea  associated  with  ovarian  disease  that  a  h^'per- 
sesthetic  and  more  or  less  inelastic,  if  not  contracted,  condition  of  the 
endometrium  has  been  the  real  cause  of  the  dysmenorrhoea. 

I  have  had  very  little  satisfaction  in  the  use  of  medicine  in  curing 
dysmenorrhoea  by  any  specific  action,  and  I  only  use  anodynes  as  pal- 
liatives in  case  of  severe  pain  until  the  dysmenorrhoea  is  stopped  by 
improving  the  general  health  or  by  local   treatment. 

To  illustrate  what  I  consider  to  be  the  best  plan  of  treating  typical 
cases  of  dysmenorrhoea,  I  will  describe  the  different  steps  that  I  am 
in  the  habit  of  pursuing  in  my  private  practice. 

A  young  woman,  say  of  seventeen  years,  is  brought  to  me  by  her 
mother.  After  taking  a  careful  history  of  the  case,  inquiring  especially 
as  to  any  disease  or  sickness  that  she  may  have  had  since  nine  years  of 
age,  and  as  to  her  mode  of  life  and  studies  during  that  time,  I  do  not 
at  first  advise  a  local  examination,  but  make  sufficient  examination  to 
detect  any  signs  of  a  complicating  or  constitutional  disea.se.  If  she  is 
inclined  to  constipation,  I  order  either  pulv.  glycerrhiz.  co.  to  be  taken 
at  bedtime,  or  fl.  ext.  cascara  before  meals.  I  prefer  these  i^reparations, 
for  I  know^  that  thev  mav  be  used  Avithout  necessarily  fostering  the  fixed 


426  MENSTRUATION,   AND  ITS  DISORDERS. 

habit  of  using  laxatives.  If  she  is  aneemic  I  order  Blaud's  pills,  one 
after  each  meal,  as  being  one  of  the  best  forms  in  which  to  give  iron.  If 
she. complains  of  being  tired  and  wakeful  or  nervous,  I  order  a  tablespoon- 
ful  of  the  syrup  of  the  hypophosphites,  to  be  taken  after  meals.  If  her 
appetite  is  poor  or  there  are  more  marked  evidences  of  faulty  assimila- 
tion, I  order  a  glass  of  pancreatized  milk  with  each  meal,  or  a  bottle 
of  Brush's  koumyss  twice  a  day.  If  she  is  at  school  she  is  ordered  to 
give  it  up  and  to  spend  much  of  her  time  in  the  open  air,  and  to  come 
iu  contact  with  healthful,  agreeable  ]3eople  whose  presence  does  not 
excite  or  exhaust  her.  This  plan  of  general  treatment  will  often  give 
relief  in  a  few  months,  and  if  persevered  in  will  in  simple  cases  eifect 
a  cure  without  any  local  treatment,  which  on  account  of  its  disturbing 
and  trying  effect  on  sensitive  girls  is  to  be  avoided  if  possible.  If  the 
above  fails  after  a  fair  trial,  then  I  order  in  addition  that  hot  vaginal 
douches  be  properly  given  for  ten  days  previous  to  each  menstruation. 
If  this  does  not  steadily  improve  the  condition  of  the  patient  and 
lessen  the  dysmenorrhoea,  I  then  advise  a  local  examination.  In  cases 
of  long  standing  the  ostium  vaginae  may  be  found  extremely  sensitive 
and  abnormally  contracted — in  fact,  in  a  state  probably  not  unlike  that 
of  the  endometrium.  In  these,  on  account  of  the  hypersesthesia,  etheriza- 
tion may  be  required  to  obtain  even  a  simple  examination  with  the  index 
finger.  While  the  patient  is  under  ether  it  is  well  to  thoroughly  dilate 
the  vagina,  so  as  to  lessen  the  pain  of  subsequent  treatment. 

After  ascertaining  the  condition  of  the  uterus  and  other  organs  as  far 
as  practicable,  I  at  once  begin  treatment  by  the  application  of  pledgets 
of  cotton  saturated  with  a  mixture  of  pure  glycerin  and  boro-glyceride : 
the  latter  is  an  antiseptic  and  prevents  fermentation,  etc.  that  may  follow 
the  use  of  simple  glycerin.  The  applications  are  made  to  the  vagina 
twice  a  week,  kept  in  for  twenty-four  hours,  and  vaginal  douches  given 
when  removed.  They  will  cause  a  free  watery  vaginal  discharge,  and 
after  two  or  three  weeks  will  soften  and  render  less  sensitive  the  vagina 
and  enable  you  to  freely  move  the  uterus.  In  well-marked  cases  of 
dysmenorrhoea  the  uterus  will  be  found  abnormally  small,  the  cervix 
pointed  and  hard,  with  its  axis  parallel  with  that  of  the  vagina,  the 
intravaginal  anterior  lip  being  very  short  and  the  posterior  long;  and 
the  fundus  will  usually  be  flexed  forward.  If  the  patient  gives  a  his- 
tory of  habitual  constipation,  the  left  broad  ligament  will  give  evidence 
of  having  been  stretched,  and  the  left  ovary  will  be  found  prolapsed  to 
the  level  of  the  vaginal  junction,  and  the  broad  ligament  feel  full  and 
elastic  on  account  of  the  varicosed  state  of  the  pampiniform  plexus — a 
condition  similar  to  varicocele  in  the  male.  There  may  be  a  leucor- 
rhoeal  discharge,  with  a  slight  granular  eroded  condition  of  the  endo- 
metrium in  and  around  the  os  externum.  After  rendering  the  uterus 
movable  by  this  preparatory  treatment,  and   having  ascertained  the 


D  YSMENOn  II  IKEA . 


427 


Fio.  171. 


absence  of  any  (•()iiij)lic;itiiiti,-  pc  riiitciiiir  inllanunation,  the  va<rina  is 
swabluHl  out  M-itli  a  sol.  hidildi-.  hut.,  1  to  ."}()()(),  and  tlien  a  clean 
sound  is  passed  for  the  first  time.  ^Vs  a  rule,  it  should  be  curved  to 
suit  the  degree  of  flexion.  As  it  reaches  and  passes  the  os  internum 
the  i)atient  will  complain  of  the  same  j)ain  as  that  caused  by  mciistnia- 
tion,  and  as  the  sound  is  withdrawn  a  little  blood 
mav  show  itself  at  tiie  os  extenuuii.  Having  had 
the  case  under  prei)aratory  treatment  k)ng  enough 
to  be  sure  of  a  correct  diagnosis,  and  having  rcn- 
tlcrcd  tlic  uterus  movable,  and  feeling  satisfied  that 
there  is  no  ju'riuterine  disease,  such  as  a  distended 
tube  to  be  ruptured  during  the  act  of  dilating  the 
cervix,  the  case  may  be  considered  ready  for  the 
next  step  in  the  treatment — namely,  dilatation.  But 
if  the  case  is  complicated  by  periuterine  congestion 
or  "subacute  inllammation,"  the  simple  glycerin 
])le(lgets  are  replaced  by  similar  pledgets  saturated 
with  a  mixture  of  alum  one  part  to  pure  glycerin 
fifteen  parts  and  one  part  of  boro-glyceride.  The 
size  of  the  pledgets  is  gradually  increased.  As  a 
rule,  an  ordinary  case  M'ill  be  much  changed  in  two 
or  three  weeks  by  this  preparatory  treatment ;  the 
vagina  is  less  sensitive  and  larger;  the  cervix  is  less 
pointed  and  its  axis  directed  farther  backward ;  the 
periuterine  tissues  are  softened  and  less  painful  upon 
examination.  Occasionally  a  case  of  long  standing, 
in  which  the  nervous  system  has  been  seriously  af- 
fected, will  require  six  or  eight  weeks  of  such  treat- 
ment before  the  next  step  can  be  safely  undertaken. 
Dilatation. — The  patient  being  in  Sims's  position, 
the  vagina  is  sponged  out  with  a  solution  of  1  to  3000 
bichloride  or  1  to  20  of  carbolic  acid.  All  instru- 
ments are  kept  in  a  solution  of  carbolic  acid.  Then 
a  Sims  uterine  dilator  is  inserted  in  the  uterine  canal. 
By  allowing  the  instrument  to  ascend  with  the  ut(M'us 
to  the  vault  of  the  vagina  and  carefully  watching  the 
amount  of  separation  of  the  blades,  there  will  be  no 
danger  of  the  dilators  slipjiing  and  the  degree  of 
dilatation  can  be  readily  regulated.  The  dilator, 
Avhen  j)roperly  curved,  can  be  passed  almost  as  easily  as  a  curved 
sound ;  the  blades  should  be  forced  apart  about  four  lines.  The 
amount  of  force  required  for  this  dilatation  will,  of  course,  vary 
greatly,  but  usually  in  old  cases  it  is  considerable,  especially  those  of 
the  imperfectly  developed  t^qie.     This  procedure  causes  more  or  less 


irodified  Sims  Dila- 
tor, made  of  steel  so 
tempered  that  the 
blades  will  remain 
parallel  under  200 
pounds  of  pressure. 


428  MENSTRUATION,  AND  ITS  DISORDERS. 

(and  in  some  cases  intense)  pain,  similar  to  that  due  to  menstruation. 
The  dilator  is  withdrawn  and  the  cervical  protector  introduced  into 
the  OS  internum.  An  applicator  previously  wrapped  with  cotton  is 
dipped  into  pure  carbolic  acid ;  the  free  acid  having  been  rubbed 
off,  it  is  passed  through  the  tube  of  the  cervical  protector  directly 
through  the  os  internum,  and  thoroughly  applied  by  turning  it  about 
and  slightly  withdrawing  the  tube  and  applicator.  About  twenty 
grains  of  iodoform  are  blown  against  the  cervix  as  the  speculum  is 
withdrawn.  In  some  cases  the  pain  is  immediately  relieved ;  rarely 
the  patient  complains  of  cramping  pain  for  several  hours.  AVhen  prop- 
erly performed  as  directed  above,  and  if  antiseptic  precautions  were 
used,  I  have  never  seen  any  harm  from  this  treatment  in  uncomplicated 
cases.  The  first  dilatation  can  be  made  at  the  patient's  home,  and  she  is 
kept  in  bed  for  the  rest  of  the  day  or  until  all  disturbance  has  ceased. 
As  a  rule,  it  is  best  to  allow  at  least  a  week  to  pass  before  the  dilatation 

Fig.  175. 


i.'RaV^DLRS-tO. 


Wylie's  Cervical  Protector,  made  and  used  fourteen  years  ago :  three  sizes. 

is  repeated.  The  glycerin  pledgets  can  be  inserted  as  usual.  Some- 
times I  repeat  the  dilatation  three  times  between  the  menses,  but  usually 
twice  is  sufficient ;  and  if  the  dilatation  can  be  carried  to  the  point  where 
the  blades  are  four  lines  apart  at  the  os  externum,  the  dysmenorrhoea  is 
relieved  in  the  majority  of  cases  where  there  is  no  active  endometritis  or 
endocervicitis,  and  in  favorable  cases  it  is  the  beginning  of  a  permanent 
cure.  Much  will  depend  upon  the  condition  of  the  general  health  and 
on  the  readiness  with  which  the  lining  membranes  of  the  uterine  canal 
respond  to  the  treatment.  AYhere  the  tissues  are  not  sensitive  and  the 
uterus  is  small  and  atrophied,  I  use  iodine  in  place  of  carbolic  acid,  or 
I  applv  electricity  directly  to  the  uterine  tissues  and  persist  in  the  treat- 
ment until  the  uterus  develops. 

Besides  the  vaginal  and  periuterine  hypersesthesia,  any  complica- 
tion, such  as  vaginitis,  acute  endocervicitis,  metritis,  or  local  peritonitis, 
should  be  treated  before  resorting  to  dilatation  for  the  removal  of  dys- 
menorrhoea. In  those  cases  Avhere  catarrhal  disease  and  anaemia  are 
active  agents  in  causing  the  disease  or  hypersesthesia  at  the  os 
internum,  the  dysmenorrhoea  will  of  course  be  likely  to  return,  unless 
these  conditions  are  permanently  corrected.  The  changes  produced  by 
this  treatment  are — a  shortening  of  the  cervix,  a  nearer  approach  to 
the  normal  direction  of  the  axis  and  shape  of  the  vaginal  cervix,  and 
a  complete  alteration  in  the  mucous  lining.     Any  subacute  congestion 


T)YSMi:x()in:u<K.[.  420 

witli  faulty  socrotions  is  usually  cund,  the  secretions  of  the  cervix 
beconiiuj^  transparent  like  the  white  of  au  egjr.  After  this  treatment 
a  sound  can  be  })a.ssed  to  the  I'undus  without  causinj^;  pain.  This  simple 
method  of  dihitinji;  and  the  use  ol"  the  cervical  pnjtector  enable  one  to 
make  ell'ectual  application  to  (he  linin>i  membrane  of  the  uterus,  ^^'ith- 
out  dilatation  ai)plicati(ins  to  the  endometrium  are  out  of  the  (juestion, 
and  without  the  cervical  protector  most  of  the  solution  w(tuld  be 
absorbed  or  rubl)ed  or  squeezed  oif  by  the  walls  of  the  cervix. 

Vivn/.sion. — In  married  M'omen,  if  nothing  is  done  to  prevent  impreg- 
nation, sterility  will  often  be  cured  by  this  simple  dilatation.  But  in  a 
certain  number  of  cases  this  method  gives  only  temi)orary  relief  The 
vaginal  part  of  the  cervix  is  abnormally  long  and  pointed  and  hard, 
and  does  not  shorten  np  after  dilatation,  and  the  stenosis  is  accompanied 
by  so  great  a  change  in  the  muscular  walls,  or  there  is  so  strong  a  tend- 
ency to  spasmodic  contraction  of  the  os  internum,  that  simi)le  dilata- 
tion will  not  cure  the  dysmenorrhcea  or  sterility,  and  it  becomes  neces- 
sary to  resort  to  divulsion  or  a  modification  of  Sims's  operation,  A\hich 
is  a  combination  of  divulsion  and  incision,  with  the  use  of  a  hard- 
rubber  intra-nterine  drainage-tube  instead  of  a  glass  plug  or  stem 
pessary.  I  employ  the  above  preparatory  treatment  with  pledgets  of 
cotton  saturated  with  glycerin,  etc.,  always  carefully  treating  any  com- 
plication, such  as  periuterine  inflammation,  beforehand ;  for  as  long  as 
the  uterus  is  fixed  by  old  adhesions  any  dilatation  or  operative  pro- 
cedure is  attended  with  risk.  AVhen  the  uterus  is  movable,  so  that  the 
cervix  with  little  resistance  or  pain  can  be  pulled  well  down  to  the 
vulva  while  the  patient  is  in  Sims's  position,  it  is  usually  safe  to 
operate.  ]\Iy  patient  is  instructed  to  take  a  laxative  and  bath,  to  have 
fresh  clothing,  bedding,  etc.,  and  to  take  a  vaginal  douche  of  solution 
of  bichloride,  1  to  3000,  preparatory  to  the  operation.  Instruments 
needed :  one  dozen  sponge-holders,  with  new  aseptic  sponges ;  Sims's 
speculum,  depressor,  forceps,  sound,  tenaculum,  uterine  dilator,  appli- 
cator, hard-rubber  drainage-tube,  a  needle-holder,  and  a  threaded 
slightly  curved  needle  with  silver  wire, 
to  be  used  in  case  the  circular  artery  is    ^  ig.    -  . 

severed.  A  straight  bistoury  can  be 
used  in  place  of  a  Sims  uterotorae,  and, 
unless  the  tissues  above  the  os  internum 
are  to  be  divided,  it  will  do  nearlv  as 

,,         rr<i  •  n  '•  Wylie's  Hard-niliber  Intra-uterine  Drain- 

well,        lliese    instruments    are    all    im-       age-tu1)e.  nine    in    set.  three    sizes  ill 

mersed  in  o-per-cent.  solution  of  car-     I'-^nfth- an*^  three. calibres ;  Nos. is, 20, 

1  and  22  (American  measure). 

bolic  acid.     The  patient,  being  ether- 
ized, is  put  in  Sims's  position ;  the  vagina  is  carefully  s]X)nged  out  with 
1  to  3000  bichloride  solution  ;  a  strong  tenaculum  is  fixed  in  the  anterior 
lip  of  the  cervix,  ^vhich  is  ]iulled  to  the  vulva.     "With  the  sound  the 


430  MENSTRUATION,  AND  ITS  DISORDERS. 

uterus  is  explored  ;  the  dilator  is  then  introduced,  and  the  uterine  canal 
slightly  dilated,  so  as  to  allow  the  blade  of  the  bistoury  to  pass  readily. 
If  the  shape  and  condition  of  the  cervix  requires  it,  the  cervix  is  divided 
posteriorly.  The  blade  of  the  latter  is  then  introduced,  cutting  edge 
backward,  up  to  the  os  internum  or  the  point  of  flexion ;  the  posterior 
wall  of  the  cervix  is  divided  in  the  median  line  for  half  an  inch  or 
more,  according  to  the  length  of  the  infravaginal  jDart  of  the  cervix ; 
the  lining  mucous  membrane  is  divided  the  full  length  of  the  cervix ; 
and  the  muscular  walls  are  also  divided  for  some  distance  under  the 
external  mucous  membrane  covering  the  infravaginal  cervix.  As  a 
rule,  there  is  very  little  bleeding,  and  where  the  circular  artery  is 
normally  placed  it  will  not  be  divided.  It  is  a  mistake  to  divide  all  the 
muscles,  and  especially  the  vaginal  mucous  membrane  of  the  cervix,  as 
far  as  the  vaginal  junction.  After  this  incision  the  dilator  is  introduced 
and  the  os  internum  freely  divulsed.  Dr.  Sims  always  divided  the 
anterior  wall  at  the  os  internum  with  his  uterotome,  but  I  have  for 
several  years  past  trusted  to  the  dilators  to  overcome  all  constriction  at 
this  point,  for  I  have  never  seen  a  full-sized  plug  introduced  after  the 
incision  through  the  os  internum  without  the  free  use  of  the  dilators. 
The  dilatation  should  be  done  slowly,  so  as  to  give  time  for  the  tissues  to 
stretch  and  not  tear.  In  many  cases  the  amount  of  force  needed  to- 
overcome  the  constriction  is  very  great — not  less  than  the  full  force 
of  the  grip  of  one  hand ;  if  this  force  be  kept  up  for  a  minute  or  two, 
it  will  usually  suffice,  and  it  is  well  to  repeatedly  try  to  introduce  the 
intra-uterine  drainage-tube,  and  to  be  satisfied  with  the  amount  of  dila- 
tation when  a  full-sized  moderately  curved  tube  can  be  introduced  to 
its  full  length  (two  and  a  quarter  inches),  and  remains  in  place  without 
being  held  in  position.  It  is  at  this  point  of  the  operation  that  failure 
is  often  made,  for  many  times  the  point  of  the  tube,  especially  if  straight,, 
strikes  at  the  os  internum  at  the  point  of  flexion,  and  forms  a  j)ouch 
beliind  it,  which,  with  the  elongation  caused  by  the  stretching  of  the 
cervix,  allows  the  tube  to  enter  the  cervix  almost  to  its  full  length. 
This  leads  the  operator  to  think  that  it  has  entered  the  cavity  of  the 
fundus,  and  he  inserts  his  tampon,  etc.  Now,  the  test  whether  the  tube 
has  passed  the  os  internum  and  entered  the  cavity  of  the  fundus  is,  that 
it  will  remain  in  place  and  not  tend  to  spring  back  ancl  out  as  soon  as 
pressure  is  removed.  Once  it  is  well  through  the  os  internum,  it  i& 
grasped  by  the  circular  fibres  and  remains  in  place.  In  some  cases,  of 
course,  it  is  more  difficult  to  pass  the  tube  than  in  others.  Where  the 
flexion  is  decided  and  the  lining  membrane  of  the  cervix  lax,  the  point 
of  the  tube  invariably  glides  behind  the  os  internum  and  puts  the 
lining  membrane  and  the  posterior  wall  of  the  cervix  on  the  stretch. 
More  than  once  I  have  seen  this  operation  done,  and  the  tampon  put 
in  to  hold  the  tube  forcibly  in  place,  and  afterward  had  the  opportunity 


j)YsMi:s(n:i:ii(i:.{.  WW 

to  j)rov('  that  the  cavity  nf  the  I'liiidiis  Imd  ii(»t  hccu  ciitcrcfl  hy  citlicr 
tlic  kiiill"  or  tiil)i'.  KvcM  ill  the  liaiids  of  Dr.  Sims  liiiiix-Il"  I  liavc  seen 
lailiirc  to  <jet  a  good-sized  liiass  |)liij;'  in  at  one  sittiii<:.  I  am  *)iiilc  <cr- 
taiii  tliat  this  diilictdty  accounts  lor  some  ot"  the  t'aihires  to  do  "rood  hy 
this  opi'i'atioii.  In  certain  eases  it  wonhl  seem  next  to  imjtossihh-  to 
intro(hiee  Simpson's  or  IVaslee's  ntei'(iti>me,  or  any  straiglit  in.-trnmcnt, 
withont  first  dihitint;-  the  external  os  by  tents  or  other  means  to  I'chix 
the  OS  internum  and  sti-aiiihten  the  canal.  Straij^ht  dilators  may  ho 
made  to  pass  up  int<i  the  cervix  two  inches  or  even  more,  but  they  will 
])ush  the  OS  forward  or  to  one  side,  and  will  not  enter  the  cavity  «»f'  the 
liuulus  of  the  uterus,  characteristic  cases  heediutj;  dilatation.  1  have 
had  Sims's  dilator  made  with  blades  curved  so  that  it  can  be  passed  as 
readilv  as  a  sound.  Tt  should  be  of  the  very  best  steel,  so  as  not  to 
yiekl  under  pressure,  and  the  joints  should  be  sufficiently  far  back  to 
allow  the  blades  to  open  and  yet  remain  nearly  parallel.  The  joint  is 
held  by  an  adjustable  screw  that  enables  it  to  be  taken  a[)art  to  be 
cleanetl. 

When  the  tul)e  can  be  readily  pa.ssed  into  and  through  the  os  inter- 
num, it  is  Mcll  to  a[)ply  a  little  pure  carbolic  acid  on  an  api)licator  to 
the  lining  membrane  of  the  cervix,  then  to  replace  the  plug,  cleanse  the 
vagina,  and  blow  into  it  a  half  drachm  of  iodoform ;  this  is  absorbed 
more  slowly  and  remains  longer  than  any  other  antiseptic.  Dr.  Sims 
made  it  a  rule  to  insert  styptic  cotton  against  the  plug  and  cervix,  and 
then  over  this  a  firm  tampon,  the  object  being  to  prevent  hemorrhage 
and  at  the  same  time  keep  the  plug  in  place.  I  do  not  place  the  pledg- 
ets until  the  hemorrhage  is  completely  checked,  and  usually  the  pres- 
sure of  the  tube  stops  the  oozing  if  there  is  any.  If  the  circular  artery 
is  cut,  I  ligate  it  by  passing  a  silver  suture  around  and  twisting  it. 
When  all  oozing  has  ceased  and  the  tube  is  in  place,  pledgets  of  cotton 
squeezed  out  in  1-to-oOOO  bichloride  solution  and  sprinkled  with  iodo- 
form are  put  under  and  in  front  of  the  tube,  the  object  being  to  keep 
the  tube  in  position.  After  each  urination  the  vulva  should  be  washed 
with  antiseptic  .solution  (bichloride  1  to  5000),  and  iodoform  sprinkled 
over  it  for  .several  days.  On  the  third  day  I  remove  the  cotton  and 
in.sert  fresh  pledgets  after  thoroughly  cleansing  the  vagina,  the  tube 
being  left  undisturbed.  On  the  sixth  or  seventh  day  I  remove  the  tube, 
and  after  cleaning  it  and  the  vagina  I  replace  it  and  keep  it  in  position 
either  with  iodoform  cotton  pledgets  or  a  vaginal  pessary.  It  is  allowed 
to  remain  for  a  week  or  two  longer  as  the  case  may  seem  to  require  it. 
Dr.  Sims  usually  removetl  the  tube  on  the  fifth  day  and  left  it  out,  but 
I  prefer  to  retain  it  in  place  until  the  surface  is  entirely  healed.  Unless 
the  tube  is  a  verv  large  one  it  can  .safely  be  left  in  place  during  men- 
struation. I  use  intra-uterine  drainage-tubes  which  have  one  or  more 
deep  grooves  in  them,  so  as  to  permit  free  drainage,  and  my  objection 


432  MENSTRUATION,   AND  ITS  DISORDERS. 

to  the  iron  or  styj^tic  cotton  and  large  firm  tampons  is  that  drainage  is 
obstructed,  and  thus  the  risk  of  septicaemia  increased,  and  the  fluid 
dammed  back  in  the  uterus  may  be  forced  into  and  through  the  tubes 
into  the  peritoneal  cavity.  When  the  case  has  been  properly  prepared 
and  the  above  precautions  have  been  taken,  the  risk  is  very  slight  and 
the  result  most  satisfactory.  To  get  good  results  one  must  do  all  that 
can  be  done  to  improve  the  general  health  of  the  patient  and  give  the 
proper  preparatory  treatment,  which  not  only  lessens  the  chances  of 
doing  harm,  but  also  enables  one  to  carefully  study  the  case  and  patient 
and  eliminate  complications,  such  as  diseased  tubes  or  ovaries,  etc.  If 
one  takes  a  delicate  and  weak  woman  with  an  imperfectly  developed 
uterus,  with  a  degenerate  and  granular  eroded  mucous  lining,  and 
divides  the  cervix  too  freely,  or  when  discission  is  not  needed,  he  may 
relieve  the  dysmenorrhoea,  but  he  will  do  his  patient  harm,  and  sooner 
or  later  she  may  have  an  everted  and  diseased  cervix  resembling  a 
lacerated  cervix  and  requiring  the  same  treatment. 

If  one  divulses  the  cervix  or  divides  it  with  a  knife  while  the  patient 
has  a  diseased  tube  tense  with  an  irritating  or  poisonous  fluid  or  a  dis- 
eased ovary  filled  with  tense  cysts,  any  of  these  may  burst  or  break  and 
cause  local  peritonitis.  Or  if  one  operates,  without  using  antiseptics  or 
preparatory  treatment,  upon  a  patient  with  a  diseased  mucous  mem- 
brane, he  may  cause  the  extension  of  the  local  poisoning  to  the  deeper 
literine  or  periuterine  tissues,  and  get  what  we  call  inflammation ;  but 
this  is  the  fault  of  the  operator  and  not  of  the  operation.  Eliminate 
failures  to  diagnose  serious  complication,  and  blood-poisoning  from 
lack  of  care  in  cleanliness  or  from  prejudice  against  the  use  of  anti- 
septics, and  this  operation  becomes  one  of  the  simplest  in  uterine 
surgery. 

I  have  never  believed  in  the  necessity  of  the  bilateral  operation.  In 
those  cases  where  Dr.  Sims  recommended  it  I  would  dilate  and  drain 
or  divulse  and  keep  open  with  a  drainage-tube. 

If  the  dilatation  is  imperfectly  done,  the  relief,  of  course,  is  only 
temporary,  but  when  thoroughly  done  and  repeated,  say  twice  in  two 
or  three  months,  it  will  often  effect  a  permanent  cure  in  cases  of  even 
ten  years'  standing.  I  know  several  whom  I  treated  as  long  ago  as  six 
or  eight  years,  and  they  are  well  to-day.  Undoubtedly,  there  are  cases 
that  can  be  relieved  of  dysmenorrhoea,  but  not  cured  of  sterility ;  for 
there  are  some  cases  in  which  the  organs  have  reached  only  a  very  im- 
perfect degree  of  development,  or  have  atrophied  and  changed  so  much 
that  they  cannot  be  fully  developed  by  any  treatment.  In  some  of 
these  the  local  application  of  electricity  will  do  good  by  stimulating 
development.  It  is  a  simple  matter  to  apply  electricity,  but  its  use 
must  be  kept  up  for  several  weeks  before  it  will  have  a  perceptible 
effect.     The  galvano-electric  pessary  of  Simpson  may  be  used  in  cer- 


i)YsMi:y(jnnii(K.  i .  433 

tain  indolent  cases,  htit  it  innst  be  closely  \vat<'lie<l.  A  jxood  drainajxo- 
tnhe  ol"  hard  rnl»l)er  is  nnicji  safer  and  |»erliaj)s  e»|iially  ellicacions.  If 
a  woman  witii  dysinenorrluea  is  (o  many,  she  shoidd  marry  early  in 
lile,  ft>r  the  chances  of  ])re<^nancy  and  fnll  (h-veloj»ment  then  are 
undonhtcdly  better  than  later.  I  am  certain  it  hel|)s  these  eases,  for 
normal  erotic  excitement  stimidates  de\('l(i|)iii(  iit  and  ascits  alniormal 
fnnctional  deranirement  and   bad  habits. 

C'hildbearing  is  the  best  means  of  completing  devel()|»iiient  and  mak- 
ing a  permanent  cnre  in  such  cases.  One  would  expect  that  small,  im- 
perfectly-developed uteri  would  be  torn  more  frequently  than  in  the 
average  case  of  labor;  and  this  is  a  fact,  especially  if  the  labor  is  qui(;k, 
for  the  cervix  requires  time  to  get  into  the  best  condition  for  full  expan- 
sion. I  have  foiuid  tiiat  more  depends  upon  the  condition  of  tiie  mucous 
membrane  at  the  time  of  laceration  and  shortly  after  labor  than  uj)on 
the  size  of  the  os  or  the  extent  of  the  tear.  Diseased  tissues  heal  badly 
and  tend  to  swell,  evert,  etc. 

Sponge  Tents. — For  more  than  ten  years  I  have  not  usetl  tents  in 
these  cases.  Without  doubt,  some  cases  can  be  cured  with  them,  but 
their  use  is  more  dangerous  than  that  of  the  dilator,  and  much  more 
inicertain  in  results.  If  tents  must  be  used,  I  have  them  made  with 
iodoform  mixed  in  the  gum,  and  I  use  iodoform  and  bichloride  tam- 
pons to  keep  them  in  place.  I  never  allow  them  to  remain  more  than 
twelve  hours,  for  they  fjrm  a  most  excellent  nidus  for  germs,  and  for 
a  time  they  prevent  drainage  from  a  very  much  irritated,  rapidly  secret- 
ing mucous  membrane,  and  may  force  some  of  it  into  the  Fallopian 
tubes,  etc. 

Dilatation  by  Sound. — \yhenever  I  see  a  specialist  using  a  set  of 
graded  uterine  bougies  or  sounds,  especially  such  as  are  nearly  straight, 
I  know  that  he  is  travelling  over  an  old  road  that  was  pointed  out  by 
Mackintosh  many  years  ago.  The  uterus  is  too  movable  and  elastic 
to  permit  of  the  use  of  sounds  to  the  best  advantage,  and  many  a  case 
has  been  sounded  up  to  the  os  internum  and  not  beyond. 

To  Simpson  belongs  the  credit  of  the  first  uterotome,  but  Sims  was 
the  first  to  perfect  that  instrument  and  to  understand  fully  how  to  use 
it.  He  pointed  out  the  mistake  of  using  automatic  and  straight  utero- 
tomes  in  the  uterus. 

In  June,  1873,  Dr.  John  Ball  of  Brooklyn,  X.  Y.,  read  a  ]>aper 
before  the  Medical  Society  of  Kings  county  on  rapid  dilatation  of  the 
cervix  uteri  for  the  relief  of  stricture,  etc.,  and  in  1877  he  presented  a 
paper  on  the  same  subject  before  the  New  York  State  ^Icdical  S(X'iety. 
About  this  same  time  Ellinger  of  Stuttgart  advocated  forcil)le  dilata- 
tion. Dr.  Ball  reported  a  number  of  cases  successfully  treated  by  rapid 
dilatation,  and  in  this  country  introduced  the  method  of  **  rapid  dilata- 
tion "  now  so  earnestly  advocated  by  Dr.  Goodeli,  whose  methods  are 

Vol.  I.— 23 


43-t  MENSTRUATION,  AND  ITS  DISORDEBS. 

essentially  those  of  Dr.  Ball.  There  can  be  no  question  about  the  suc- 
cess of  divulsion,  but  there  are  many  cases  which  can  be  perfectly  cured 
by  moderate  dilatation,  which  is  not  only  less  dangerous,  but  I  think 
gives  better  results  in  those  cases  where  imperfect  development  is  more 
marked  than  spasmodic  stricture.  For  it  is  not  a  powerful  and  spas- 
modically constricting  muscle  that  is  to  be  overcome,  but  a  feeble, 
degenerate  organ  that  needs  to  be  stimulated  to  healthy  development. 
In  cases  of  atresia  of  the  cervix  where  the  vaginal  cervix  is  large  and 
only  slightly  flexed  and  pointed,  where  Dr.  Sims  advised  the  bilateral 
incision,  I  use  divulsion  and  insert  a  drainage-tube;  and  I  do  the 
same  in  cases  of  chronic  catarrh  where  there  is  indication  of  strict- 
ure of  the  cervix.  But  when  I  am  treating  sterility,  and  have  a  flexed, 
hard,  and  pointed  cervix  to  deal  with,  I  am  sure  that  the  knife,  applied 
as  above  advocated,  is  an  improvement  upon  simple  divulsion,  for  the 
OS  externum  tends  to  contract  and  close  the  opening  after  the  latter 
operation  unless  the  tissues  are  torn  by  the  instrument.  Still,  I  con- 
fess that  we  could  more  easily  dispense  with  the  uterotome  than  with 
uterine  dilators.  There  is  less  risk  in  opening  the  uterine  canal  with 
dilators  than  with  the  uterotome,  but  dilators  can  do  serious  harm  when 
the  dilatation  is  carried  too  far ;  and  if  one  uses  a  screw  to  force  open 
the  dilators  the  risk  is  greater  than  when  he  uses  his  hand  or  hands  to 
regulate  the  amount  of  dilatation. 

Use  of  Pessaries  in  Dysmenorrhoea. — If  the  use  of  pessaries  in  such 
cases  had  never  been  taught,  much  harm  would  have  been  averted  and 
more  progress  made  in  the  right  direction.  Only  very  rarely  can  we 
afford  some  relief  by  the  use  of  an  anteflexion  pessary,  but  at  best  it 
is  only  palliative  and  can  be  dispensed  with.  It  is  not  so  much  by 
straightening  the  flexion  that  the  pessary  does  good  as  by  preventing 
prolapse,  and  perhaps  by  steadying  the  fundus.  As  to  the  use  of  stem 
pessaries  for  straightening  the  canal,  they  may  do  good  by  stimulating 
development,  but  many  of  them  are  dangerous  instruments. 


Membranous  Dysmenorrhcea. 

If  we  could  accept  the  desquamative  theory  of  Dr.  John  "Williams, 
it  would  be  easy  to  explain  membranous  dysmenorrhoea ;  and  if  the 
view  advocated  by  Kundrat  and  Engelmann  of  the  growth  of  the 
utricular  glands  and  proliferation  of  round  cells  before  menstruation, 
and  the  exfoliation  of  this  proliferated  mucous  membrane  during  the 
flow,  is  correct,  then  we  could  say  that  membranous  dysmenorrhcea  is 
merely  an  exaggeration  of  a  normal  process,  and  the  membrane  comes 
away  en  masse  instead  of  in  minute  particles. 

I  am  inclined  to  believe  that  the  process  which  takes  place  in  the 


MI:MIII!.1\(K\S  DYSMENOIHIIKEA.  4.'i.j 

ii(cnis  luid  Icatls  ii|)  tn  nicMstniatioii  is  una  of"  growth — a  pn'j)aratinii 
lor  Mrcuiiancv  (similar  tu  the  luiti'ilivr  node  tliat  pr('('(!(k'.s  the  formation 
of  a  l>ii(l  oil  a  tree,  as  Mary  l'iiiiiaiii-.]ai(»l)i  wdultl  express  it) — ami, 
iiiilfss  impreiiiiatioii  takes  place  ami  stimulates  and  directs  further 
"■rowtli,  that  disiuti\u,ratioM  will  take  |)laee  and  the  aecunudated  blood 
escape  and  the  tissues  ai;ain  start  another  eyelo  of  lii-owth.  If  this  dis- 
inteii-ration  takes  place  by  fatty  degeneration,  and  the  lower  or  under- 
Ivini;  part  deijenerates  before  the  superfieial  part  disintej^rates,  the 
latter  mav  be  thrown  olf  in  shreds  or  ca.st  off  in  one  piece.  This 
abnormal  process  may  be  the  result  of  the  preparatory  growth  g<»ing 
too  far  in  developing  a  decidual  mcml)rane,  or  it  may  be  the  result  of 
some  irritating  disease  abnormally  increasing  tiie  supply  of  blood,  thus 
indueiijg  excessive  growth  of  the  lining  membrane,  or  the  irritation 
may  so  greatly  increase  the  normal  vascular  tension  that  the  superficial 
layer  is  dissected  off  by  hemorrhage  in  the  deeper  layer. 

PATiiOLOfTV. — The  membrane  may  be  thrown  of}"  in  separate  pieces 
or  it  may  be  expelled  in  one  piece,  a  triangular-shaped  sac  with  three 
openings — one,  the  largest,  the  os  internum  ;  the  other  two,  much 
smaller,  representing  the  openings  into  the  Fallopian  tubes.  The 
inner  surface  is  smooth,  while  the  outer  surface  is  ragged  and  shreddy. 
Small  perforations  where  the  uterine  glands  have  penetrated  can  usually 
be  detected.  It  is  undoubtedly  composed  of  the  superfcial  layer  of  the 
endometrium,  with  perhaps  an  abnormal  amount  of  connective  tissue. 

SY.Mr»T()Ms. — In  some  cases  it  would  seem  to  be  inicomplicated  by 
any  definite  disease,  and  the  membrane  is  cast  oif  in  tangible  pieces 
every  month  on  the  second  or  third  day  of  the  flow,  which  is  accom- 
panied by  severe  colicky  pains,  sometimes  of  the  most  violent  nature. 
The  flow  may  be  somewhat  intermittent,  due  probably  to  the  membrane 
]>lugging  the  os  internum.  During  the  flow  the  patient  may  be  in  an 
ex(piisitely  sensitive  or  hypcrfesthetic  state.  Other  cases  are  irregular, 
menstruation  being  at  times  nearly  normal. 

Meml)ranous  dysmenorrhoea  is  oflen  associated  with  uterine  catarrh 
and  other  diseases,  but  these  alone  do  not  account  for  it.  A  well- 
marked  case  usually  continues  as  long  as  the  patient  menstruates. 

The  decidual  membrane  of  an  abortion  may  be  mistaken  for  mem- 
branous dysmenorrhiea,  but  the  repeated  occurrence  of  the  meml)rane 
in  membranous  dysmenorrhoea  and  the  absence  of  the  villi  of  the  cho- 
rion under  the  microscope  as  a  rule  make  a  diagnosis  comparatively 
certain. 

Treatment. — To  make  sure  of  a  diagnosis  it  may  be  necessary  to 
treat,  and  if  possible  cure,  any  existing  complication.  After  this  I 
would  treat  the  tlysmenorrho?a  in  very  much  the  same  Avay  as  has 
already  been  recommended — by  free  dilatation  or  divulsion  and  inter- 
uterine  ap]ilications,  and  tiie  jn-olonged  use  of  an  intra-nterine  drainage- 


436  MENSTRiyATION,   AND  ITS  DISORDERS. 

tube.  If  all  these  measures  failed  and  the  symptoms  justified  so 
extreme  a  measure,  with  the  patient's  consent  I  would  not  hesitate  to 
remove  the  uterine  appendages  to  induce  premature  menopause.  As  a 
rule,  after  thorough  dilatation  and  the  proper  treatment  of  complications, 
the  pain  will  be  very  much  less,  and  by  the  use  of  an  anodyne  once  a 
month  the  patient  can  be  made  comparatively  well. 

I  have  seen  severe  cases  of  dysmenorrhoea  in  which  the  membrane  is 
not  cast  off  in  large,  tangible  pieces  give  almost  precisely  the  same  kind 
of  persistent  colicky  jjains  and  cause  the  same  nervously  hypersesthetic 
state,  so  that  I  have  concluded  that  the  symptoms  were  due  to  the  same 
abnormal  conditions  as  existed  in  well-marked  cases  of  membranous 
dysmenorrhoea ;  but  the  uterus  did  not  have  the  power  to  expel  the 
membrane. 

The  Menopause. 

Take  ten  or  twelve  of  the  best  known  works  on  gynecology,  and  in 
most  of  them  the  word  "  menopause  "  is  not  to  be  found  in  the  index, 
and  in  none  is  it  more  than  mentioned  incidentally. 

As  a  rule,  menstruation  ceases  between  the  ages  of  forty  and  fifty, 
the  average  being  at  about  forty-six  years  of  age.  It  may  continue 
after  fifty  or  stop  before  forty,  but  this  is  exceptional  unless  caused  by 
disease.  Cases  of  premature  menopause  have  been  reported  as  occur- 
ring under  thirty,  and  at  a  recent  meeting  of  the  New  York  Obstetrical 
Society  Dr.  T.  A.  Emmet  reported  a  case  where  menstruation  had  con- 
tinued apparently  normally  in  a  woman  seventy  years  old,  but  he  had 
not  made  any  local  examination. 

A  woman  in  jDerfect  general  health,  and  not  having  any  local  disease 
nor  any  abnormal  conditions  of  the  tissues  the  result  of  previous  local 
disease,  should  cease  menstruating  without  any  special  general  or  local 
disturbance ;  and  many  Avomen  do  pass  the  menopause  without  suffer- 
ing. But  so  common  is  it  for  women  to  have  unusual  hemorrhage  and 
suffer  greatly  from  reflex  nervous  affections  at  this  time  that  it  is  a  pop- 
ular belief,  shared  by  most  of  the  medical  profession,  that  it  is  what  any 
woman  must  expect ;  and  unless  life  is  endangered  by  hemorrhage  or 
insanity  is  imminent,  it  is  not  to  be  regarded  as  an  abnormal  thing  to  be 
carefully  investigated  and  treated.  Every  specialist  knows  how  com- 
mon it  is  for  women  between  forty  and  fifty  years  of  age  to  come  to 
him  and  say  that  for  months,  or  even  a  year  or  more,  they  have  had 
irregular  or  more  or  less  continuous  flow,  etc.,  and  on  examination  he 
has  found  cancerous  disease  so  far  advanced  that  it  is  too  late  to  give 
material  relief  "When  he  asks  why  they  did  not  come  to  be  exam- 
ined long  ago,  they  reply,  "  I  thought  it  was  only  change  of  life, 
and  my  doctor  did  not  ask  to  make  an  examination."  Hemorrhages 
from  fungous  granulations,  polypi,   and  fibroids  are  often   neglected 


THE  Mi:.\()r.\rsh'.  4:n 

li)r  the  sMiiic  rcasim  until  cNtnnic  aiiinnia  cuiujm'Is  thoiii  to  seek  re- 
lict" ("nun  .-(line  niic  nut  ,-:iti>li('il  in  tliinkiiiLi  "it  is  only  tlw  rliMiij^c; 
of  lil".'.'" 

I'lcinatnic  nicnopansc  in;iy  l»c  tlic  result  ol"  j)rolon<re(l  anienoi"rli(r>:i 
after  eonstituti(»nal  diseiise,  w  here  from  iinperfeet  <levelo|)inent  or  atro- 
pliv  from  local  disease,  eomhiiied  witli  a  l»ad  eon<lition  of  tlie  hlood, 
tlie  organs  have  peniumeiitly  lost  the  power  to  perform  their  fuiietions. 
It  is  im|)oi-tant  on  this  aeeouiit  to  examine  earcfnily  into  th(!  cause 
of  prolouii-ed  anionorrlKoa,  especially  in  those  eases  where  it  continues 
after  the  <j;eneral  health  has  been  restored.  Sometimes  stimulatin<r 
local  treatment  arrests  the  atrophy  and  restores  the  or<rans  to  a  nor- 
mal state. 

Removal  of  the  uterine  appendages  before  puberty  w(»nl<l  in  all 
probability  prevent  menstruation  in  any  case,  but,  although  it  is  the 
rule  for  the  menopause  to  be  induced  by  the  removal  of  the  tubes  and 
ovaries  after  puberty,  yet  in  some  cases  menstruation  will  continue 
where  the  ovaries  and  the  greater  part  of  the  tubes  have  been  carefully 
removed.  As  Tait's  operation  is  done  to-day,  usually,  from  a  fourth 
to  three-fourths  of  an  inch  or  more  of  the  tubes  are  not  cut  away, 
and  in  many  cases  the  greater  part  of  the  pampiniform  plexus  is  left 
intact.  Dr.  Mary  Putnam-Jacobi  in  her  description  of  her  theory 
of  menstruation  gives  the  most  rational  explanation  that  I  have 
yet  seen  why  removal  of  the  a]ipendages  does  not  always  stop  men- 
struation. 

If  menstruation  at  the  menopause  is  excessive  or  too  frequent,  its 
cause  should  be  investigated  as  carefully  as  at  any  other  time.  Fun- 
gous granulations  are  very  common  at  this  age,  and  mucous  and  fibrous 
polypi  are  especially  apt  to  develop  at  this  period.  If  neglected,  they 
may  stop  bleeding,  but  not  until  the  patient's  general  health  is  injured, 
either  from  actual  loss  of  blood  or  from  reflex  disturl)ances  caused  by 
the  granulations  or  polypi  irritating  and  preventing  the  uterus  from 
undergoing  normally  the  atro]ihy  and  other  changes  that  sliould  take 
place  at  this  age. 

Strong,  vigorous  women  may  menstruate  after  fifty,  but  when  a 
woman  past  forty-eight  years  of  age  has  excessive  or  even  full  men- 
struation and  is  anjemic,  or  is  very  nen'ous  and  at  times  has  *Miot 
flashes"  running  up  and  down  her  back,  if  the  os  is  dilated  and  the 
uterus  curetted,  either  fungous  granulations  or  a  nuicous  ])olypus  or 
fibroids  will,  as  a  rule,  be  found,  and  when  thoroughly  removed  the 
menopause  will  at  once  come  on,  and  if  the  cervix  is  occasionally 
dilated  the  nervous  symptoms  will  disappear. 

In  four  instances  where  women  long  past  the  menopause  have  come 
to  me  for  vague  nervous  symptoms  similar  to  those  common  at  the 
menopause,  on  examination,  finding  the  uterus  abnormallv  large  for 


438  MENSTRUATION,  AND  ITS  DISORDERS. 

that  time  of  life — one  was  sixty-three  years  old — I  dilated  and  re- 
moved shrivelled-up  polypi.  In  one  case  the  largest  resembled  a 
small  dried  pear.     The  final  results  were  good  in  every  case. 

In  the  spring  of  1880  a  rather  thin,  wiry  woman  was  sent  to  me  by 
Dr.  Greenough  of  this  city.  She  said  that  she  had  dysmenorrhoea 
when  young,  but  had  not  had  any  special  uterine  disease  that  she  was 
aware  of.  She  had  married  when  thirty,  and  about  five  years  later  her 
menstruation  had  ceased,  and  had  not  shown  itself  except  two  or  three 
times,  when  she  had  a  scanty  flow,  for  the  past  two  years,  and  that  dur- 
ing this  time  she  had  had  hot  flashes  and  all  kinds  of  nervous  symp- 
toms, had  taken  all  kinds  of  remedies,  but  that  she  was  growing  thin, 
sleepless,  etc.,  and  that  Dr.  G.  advised  her  to  have  a  local  examination. 
I  found  the  vagina  and  uterine  appendages  normal  so  far  as  I  could 
discover;  the  uterus  was  a  little  below  the  normal  size,  but  not  as 
small  as  is  usual  two  years  after  the  menopause.  It  was  anteflexed 
and  in  about  the  normal  position.  In  and  near  the  os  the  mucous 
membrane  had  a  peculiar  coppery  or  yellowish  stained  appearance, 
which  I  had  now  and  then  seen  about  the  cervix  uteri  of  women  past 
the  menopause.  In  passing  a  sound  I  found  the  os  internum  con- 
tracted, and  as  the  sound  passed  into  the  cavity  of  the  fundus  it  gave 
exquisite  pain,  and  reminded  me  so  forcibly  of  the  condition  of  the 
uterus  so  very  common  in  young  women  suffering  with  dysmenorrhoea 
due  to  imperfect  development  that  I  made  up  my  mind  to  give  it  the 
same  treatment  as  I  ^vas  then  using  for  the  relief  of  dysmenorrhoea.  I 
gave  the  usual  preparatory  treatment,  and  dilated  the  cervix  with  a 
steel  dilator,  and  applied,  by  means  of  an  applicator  and  cervical  pro- 
tector, pure  carbolic  acid  to  the  endometrium.  I  warned  her,  as  I  do 
in  cases  of  dysmenorrhoea,  that  the  first  dilatation  might  be  quite  f>ain- 
ful  and  increase  her  nervousness  for  a  day  or  so,  but  that  the  second 
would  not  be  so  painful,  and  the  third  still  less  so,  and  that  if  this 
treatment  helped  her  I  could  probably  cure  her.  The  dilatations  were 
made  about  a  week  apart.  The  result  was  magical :  her  nervous  sys- 
tem quieted  down,  she  could  sleep,  eat  well,  and  she  steadily  improved 
in  general  health.  Twice  within  six  months  she  had  a  slight  return 
of  the  reflex  symptoms,  and  the  dilatation  and  applications  were 
repeated  with  equally  good  results.  In  a  year's  time  she  had  gained 
twenty-six  pounds  in  weight  and  claimed  to  be  perfectly  well.  Since 
then  I  have  treated  a  large  number  of  cases  suffering  from  reflex  ner- 
vousness at  and  soon  after  the  menopause  by  dilatation  and  applica- 
tions, and  with  most  excellent  success.  In  two  or  three  of  these  cases 
the  nervousness  was  extreme,  and  the  patients  had  been  through  all 
kinds  of  treatment  in  the  way  of  medication,  water-cures,  and  even 
"rest-cures,"  without  permanent  relief;  yet  they  were  cured  in  a  very 
short  time  by  dilatation  and  intra-uterine  applications. 


77//;  MESoiwrsE.  a:V.) 

In  some  cases  tlic  peculiar  :i|)|)(';ir;mci'  -it"  tlic  niiiciiiis  iiiciiiliraiic  at 
the  OS  is  M(t(  |)rcs(iit,  lait  tlic  cervix  to  the  os  iiileniiim  may  In;  per- 
fcH'tlv  noi'iiial,  and  the  suhjcetive  syiiiptoiiis  may  not  directly  point  to 
aii\-  local  disease;  yet  when  the  sound  is  passed  you  <i(.(  the  character- 
istic j)aiii,  and  ol'tcu  a  slight  How  ol"  Mood  may  escape  IVom  the  os  as 
the  sound  is  withdrawn.  The  following  case  is  a  udod  illustration  :  A 
handsome  fleshy  woman,  fifty  years  old,  marrie<l  thirty  years  and  never 
])reunant,  canu'  to  me  complaininsi;  of"  pal|)itation,  irretiular  action  of" 
the  heart,  extreme  nervousness  and  sleeplessness,  with  loss  of"  aj)petite, 
and  occasionally  an  acid  diarrhoea  the  result  of  indio(.stion.  She  had 
recently  lost  her  mother  and  two  other  members  of"  her  family,  which 
at  first  seemed  to  aeeonnt  for  her  condition.  No  organic  lesion  of  the 
heart,  kidneys,  etc.  could  be  found,  and  she  said  that  several  months 
previous  her  menses  liad  ceased  without  giving  lier  mucli  trouble,  but 
now  and  then  she  had  hot  flashes.  At  this  time  no  local  examination 
was  made,  and  for  three  or  four  months  she  was  treated  for  her  indi- 
gestion and  what  seemed  to  be  nervous  prostration ;  finally,  anodynes 
had  to  be  freel}'  used,  and  there  was  no  improvement.  In  going  over 
her  case  I  learned  that  she  had  been  treated  for  uterine  displacement  in 
early  life,  and  had  worn  a  pessary  for  ten  or  fifteen  years,  but  six  or 
eight  years  ago  had  removed  it  and  got  along  as  well  without  it  as  A^ith 
it — that  she  had  at  times  some  dragging  sensation  about  the  back  and 
sides,  and  still  had  at  intervals  the  "  hot  flashes."  She  consented  to  a 
local  examination,  I  found  great  relaxation  of  the  vaginal  walls  and 
marked  prolapse  with  the  fundus  backward.  The  cervix  seemed  per- 
fectly healthy.  The  prolapse  was  treated  by  means  of  cotton  pledgets 
saturated  with  glycerin  and  boro-glyceride-and-alum  mixture,  and  all 
local  symptoms  were  relieved,  15ut  her  reflex  nervous  symptoms  con- 
tinued. Three  weeks  later,  when  the  sound  was  introduced  the  endo- 
metrium at  and  above  the  os  internum  was  found  exquisitely  sensi- 
tive, and  the  uterine  canal  measured  three  inches  in  depth.  The 
cervix  was  dilated  and  pure  carbolic  acid  applied.  After  the  third 
dilatation  every  symptom  disai)peared,  her  menses  returned,  and  for 
six  months  were  perfectly  regular  and  she  was  in  excellent  health. 
She  passed  the  seventh  month  without  menstruating,  and  Avhen  the 
next  menses  were  due  her  heart  trouble,  indigestion,  and  nervousness 
came  back.  One  dilatation  relieved  her,  and  now  her  health  is  as 
good  as  ever. 

Whether  this  hypenesthetic  condition  of  the  endometrium  is  due  to 
a  subacute  form  of  endometritis  or  the  result  of  previous  disease  affect- 
ing the  tissues  in  such  a  way  as  to  prevent  them  from  undergoing  nor- 
mally the  changes  that  should  take  place  at  the  menopause,  is  yet  to  be 
determined ;  but  the  success  of  dilatation  of  the  cervix  uteri  and  appli- 
cations of  pure  carbolic  acid  to  the  endometrium,  combined  with  the  use 


440  MENSTRUATION,   AND  ITS  DISORDERS. 

of  cotton  pledgets  saturated  with  a  mixture  of  one  of  alum,  two  of 
boro-glyceride,  and  fourteen  of  pure  glycerin,  placed  in  the  vagina 
twice  a  week  to  stimulate  and  improve  the  circulation  of  the  pelvis, 
has  been  such  as  to  convince  me  that  much  suifering,  and  perhaps 
sonie  cases  of  insanity,  can  be  prevented  if  the  treatment  is  properly 
applied  in  well-marked  cases  of  reflex  disturbances  occurring  with  the 
menopause. 


STERILITY. 

Hy  a.    REKVRS  JACKSON.    A.M.,  M.  D. 

CnH'ACin,     ll,I,. 


AccoRDixcj  to  statistics  based  upon  many  thousands  <»f  ohsfrvatioii.s, 
al)out  one  niarrian'c  in  ten  is  untVnitf'nl.  This  tiu-t  alone  is  siiHieient  to 
estal)lisii  the  <;reat  importance  of  the  snbject  of  sterility,  whether  it  bo 
viewed  from  a  scientitic,  .social,  or  politico-economical  j)oint  of  vie\v. 

\\'hile,  in  this  article,  my  observations  will  have  reference  especially 
to  the  sterile  condition  as  it  alFccts  the  woman,  it  is  obviously  necessary 
to  notice  the  fac-t  that  in  any  ca.se  of  infertile  marriage  the  lack  may  be 
attribntable  to  the  male,  and  that  in  settling  the  diagnosis  this  po.ssibility 
should  always  be  considered.  Indeed,  the  observations  of  recent  writere 
seem  to  show  that  the  fault  lies  much  more  iVc(iuently  with  the  male 
than  has  usually  been  suppo.sed.  Thus,  Kehrer '  examined  40  ca.ses  in 
which  he  iiucstigated  both  the  male  and  female,  and,  omitting  the  con- 
sideration of  some  doubtful  ca.ses,  the  male  was  found  to  be  in  fiiult  in 
31,5  j)erceut,  of  the  entire  uiuuber,  Noeggerath  found  8  in  14;  Gros.s,^ 
basing  his  couclusions  on  the  examination  of  192  cases,  including  the 
above,  states  that  the  male  was  deficient  in  one  case  out  of  every  six. 
The  j)roportion  may  be  even  greater  than  thi.s,  for,  while  the  data 
quoted  by  Gross  are  of  much  value,  they  are  quite  insufficient  to  deter- 
mine the  question. 

The  c.s.scntial  conditions  of  human  fecundation  are  these : 

1.  Semen  containing  living  spermatozoa  must  be  deposited  within 
the  genital  pa.ssages  of  the  woman, 

2.  A  spermatozoon  must  come  in  contact  with  a  mature  healthy 
ovule  at  some  point  beyond  the  internal  os  uteri — that  is,  in  the  cavity 
of  the  uterus,  in  the  Fallopian  tube,  or  on  the  surface  of  the  ovarv, 

3.  To  enable  the  impregnated  germ  to  become  developed  into  a 
viable  new^  being  it  mast  find  a  suitable  location  for  lodgment  and 
nourishment. 

The  elaboration  and  deposition  of  the  semen  constitute  the  special 
functions  of  the  male.  Those  of  the  female  are  threefold,  and  com- 
prise the  reception  of  the  niiile  organ,  ovulation  (including  the  matura- 

»  Centralbhtt  filr  Gyncikolofjie,  No.  23,  1879.  ^  ^]/„^  Sterility. 

441 


442  STERILITY. 

tion  and  dehiscence  of  the  ovule),  and  the  furnishing  of  a  proper  nidus 
for  its  attachment  and  nutrition. 

The  necessary  functions,  then,  for  the  reproduction  of  the  human 
species  are  as  follows : 

1.  Insemination; 

2.  Impregnation ; 

3.  Ovulation ; 

4.  Gestation ; 

5.  Parturition. 

Any  one  or  more  of  these  processes  may  be  defective,  although  the 
latter  will  not  concern  the  present  inquiry. 

1.  Incapacity  for  Insemination. 

A  number  of  circumstances  may  interfere  with  the  process  of  insem- 
ination. They  may  arise  from  default  on  the  part  of  either  the  male 
or  female. 

A  man  may  possess  ample  virile  power,  the  genital  organs  may  not 
present  any  abnormality,  and  yet  semen  may  not  be  secreted ;  or,  semen 
may  be  secreted  in  proper  quantity,  but  contain  no  spermatozoa;  or,  the 
spermatozoa  may  be  few  in  number,  motionless,  or  their  movements 
may  speedily  cease  after  emission.     In  short,  the  man  may  be  sterile. 

Or  he  may  be  impotent.  By  this  term  is  understood  the  inability  to 
accomplish  the  sexual  act.  This  condition  may  depend  upon  a  variety 
of  causes,  and  may  be  absolute  or  relative,  permanent  or  temporary. 
Aside  from  vice  of  conformation  or  other  imperfection  of  the  genital 
organs,  the  defect  may  result  from  long  and  exhausting  diseases,  from 
the  premature  or  excessive  use  or  from  the  abuse  of  the  sexual  function; 
or  it  may  arise  from  purely  moral  causes.  Cases  of  the  latter  class  are 
of  great  interest  and  frequency.  Mere  timidity  sometimes  results  in 
sudden  loss  of  power  under  circumstances  in  which  it  should  be  great- 
est, the  fear  of  being  unsuccessful  sometimes  becoming  the  cause  of 
failure.  A  wife  may  by  lack  of  complaisance  cause  impotence  in  a  hus- 
band who  with  proper  encouragement  would  have  full  virile  power. 

Frigidity,  which  is  not  uncommon  in  the  woman,  is  rare  in  the  man. 
This  condition  is  characterized  not  only  by  absence  of  erection,  but  by 
absence  also  of  venereal  desire. 

Seminal  fluid  is  deposited  in  the  vagina  by  the  function  of  coition, 
the  joint  act  of  the  male  and  female.  In  this  process  the  male  is  essen- 
tially active,  while  the  female  is  relatively  passive.  With  the  former, 
erection  of  the  penis  is  necessary  to  penetration,  and  orgasm  to  ejacula- 
tion :  with  the  latter,  there  is  frequently  neither  erection  nor  orgasm. 
However,  if  the  act  be  normally  and  perfectly  performed,  both  parties 
should  participate  in  both  erection  and  orgasm. 


INCAPACITY  FOR  lySEMIXAT/nx.  443 

Tilt'  t'cinale  is  jn-oviilrcl  with  an  a|i|)ai-al  ii-  which,  iiiidi  r  strirtly  n«»r- 
inal  conditions,  is  caj)al»ic  of  clli'ctini;-  an  erection  as  coni|)lclcly  ;is  occnis 
in  the  male,  and  tlie  mechanism  is  similar  in  hoth.  Cnder  the  infln- 
cnce  of  sexual  excitement  in  the  female  MoimI  Hows  in  inerca-sed  anionnt 
to  the  cavernous  bodies  of  the  clitoiis  and  the  hulhs  of  the  va;^ina. 
These  erectile  structures  are  encircled  at  their  hiLse  hy  constricting^  uuis- 
cles  which  ohstnut  the  ictiu-n  How  of  blood,  and  cause  them  to  attiiin 
their  maxinuim  (h'^ree  of  tiiri;-escence  and  hardness.  At  the  same  time, 
the  jilans  of  the  clitoris  becomes  endowed  with  an  exalted  degree  of 
sensibility,  resulting  in  the  venereal  orgasm.  Under  the  same  excite- 
ment the  levator  ani  muscle,  embracing  the  lateral  and  posterior  por- 
tions of  the  vagina  in  the  form  of  a  dee})  crescent,  contracts  and  presses 
the  erected  penis  from  behind  and  from  both  sides  forward  against  the 
anterior  pelvic  wall  (Hildebrandt).  The  clitoris,  in  its  hardened  c(jn- 
dition,  does  not  change  its  direction,  as  does  the  male  organ,  but,  being 
fixed  by  its  frsenuni,  projects  downward  and  fVjrward  toward  the  vaginal 
orifice,  and  during  coitus  is  brought  into  nearer  contact  with  the  dorsal 
face  of  the  penis,  and  the  repeated  frictions  become  the  chief  cause  of 
voluptuous  sensations. 

The  observations  of  Litzman,^  Wernick,  Fallen/  Beck,^  Munde,  and 
others  have  shown  that  the  orgasm  affects  the  uterus  also  in  a  remark- 
able manner.  At  the  height  of  excitement  the  organ  assumes  a  more 
perpendicular  position  and  sinks  lower  in  the  pelvis.  The  os  becomes 
softer  and  rounder,  dilating  and  contracting  with  rapid  alternations, 
while  at  the  same  time  the  labia  project  and  retract  in  such  a  manner 
as  to  constitute  a  "suction"  effect,  each  gaping  being  accompanied  by 
the  emission,  almost  in  jets,  of  clear,  viscid  mucus  (Munde).  This 
process  is  of  short  duration — shorter  than  the  orgasm  in  the  male — 
and  at  its  close  the  parts  return  to  their  ordinary  state. 

Although  it  has  never  fallen  to  my  lot  to  witness  the  local  phenomena 
of  orgasm  in  the  female,  I  have,  while  making  digital  examinations, 
frequently  been  conscious  of  a  change  occurring  in  the  position  of  the 
cervix,  with  a  simultaneous  softening  of  the  part. 

Knowing  as  we  do  how  perfectly  means  are  adapted  to  ends  ever^'- 
where  in  the  construction  of  our  bodies,  it  is  reasonable  to  suppose  that 
these  provisions  would  not  exist  M-ithout  reference  to  the  perj)etuation 
of  the  species. 

Many  women  deny  absolutely  that  they  experience  any  orgasm  or 
any  degree  of  ])leasurable  sensation  during  the  sexual  act.  Such 
women  are  impotent.  The  impotency  does  not,  however,  imply  ster- 
ility, for  it  is  admitted  that  women  who  are  thus  functionally  defi- 
cient may  conceive  and  bear  children,  although  they  are  less  likely 

'  Flint's  Textbook  of  Phy.nolorfy,  1879,  p.  891. 

^  St.  Louis  Med.  and  Surg.  Journ.,  1872.  ^  Am.  Journ.  Obd.,  vol.  viii.  p.  507. 


444  STERILITY. 

to   do   so   than    those    in    whom    the    functions    are    normally    per- 
formed. 

The  causes  of  impotency  in  women,  when  purely  functional,  are  not 
understood.  The  condition  may  be  the  result  of  some  nervous  defect, 
or  in  some  cases  may  be  purely  j)sychical.  It  is  doubtless  a  not  infre- 
quent cause  of  domestic  unhappiness,  and  possibly  of  disease. 

The  sexual  sense  in  women  varies  greatly.  In  some  it  seems  to  be 
quite  as  keen  as  in  the  male ;  in  others — and  this  class  comprises  the 
greater  number — it  exists  in  moderate  degree,  its  intensity  being  in  pro- 
portion to  the  more  or  less  favorable  character  of  the  exciting  circum- 
stances. In  still  others — a  considerable  number— it  is  wholly  absent, 
or  at  least  not  evoked  by  the  sexual  act.  Even  among  this  latter  class 
it  is  possible  that  the  capacity  for  sexual  enjoyment  is  not  so  entirely 
deficient  as  is  commonly  thought,  but  held  in  abeyance  for  want  of  suf- 
ficient stimulus.  Certain  abnormities  of  the  pelvic  organs  are  known 
to  influence  sexual  desire.  Versions  of  the  uterus  have  been  known  to 
abolish  it,  the  wearing  of  a  pessary  to  restore  it,  and  the  removal  of  the 
instrument  to  be  followed  again  by  its  loss. 

Dr.  E,  J.  Ill  has  reported  ^  that  in  44  cases  in  which  trachelorrhaphy 
was  performed  for  laceration  of  the  cervix  uteri  there  were  34  in  which 
there  was  loss  of  sexual  appetite  and  orgasm  before  the  operation ;  in  1 
case  there  was  increase  (nymphomania) ;  3  of  the  subjects  were  widows ; 
and  from  5  he  could  get  no  answers  to  his  inquiries.  Of  the  34  cases, 
27  were  entirely  cured,  and  regained  sexual  desire  and  potency  after  the 
operation.  In  the  remaining  7  sexual  appetite  did  not  return.  Dr. 
Munde^  also  mentions  a  case  in  which  the  closure  of  a  laceration  of  the 
cervix  uteri  restored  sexual  power,  which  had  been  lost  apparently  by 
the  injury.  These  observations  have  an  evident  bearing  upon  the 
theory  of  uterine  orgasm,  for  a  laceration  of  the  uterine  cervix  extend- 
ing beyond  the  crown  would  obviously  interfere  with  the  alleged  suc- 
tion-power of  the  OS  uteri ;  and  if  this  constitutes  a  feature  of  the 
orgasm,  the  latter  would  be  interfered  with  also. 

On  the  contrary,  certain  other  pathological  conditions  are  known  to 
greatly  intensify  the  sexual  desire,  this  being  especially  true  of  conges- 
tion and  inflammation  of  the  ovaries.  Some  women  are  absolutely 
frigid  except  at  or  near  the  menstrual  period. 

By  some  it  is  thought  that  uterine  erection  is  necessary  to  conception, 
and  that  the  absence  of  orgasm  is  no  proof  that  some  degree  of  erection 
does  not  take  place.  Those  who  hold  this  view  believe  that  conception 
is  more  likely  to  happen  when  the  orgasms  in  the  male  and  female  occur 
simultaneously,  or  when  that  of  the  male  is  precedent ;  that  the  semen 
is  projected  into  the  uterus  at  the  moment  of  ejaculation,  or  is  drawn  in 
by  the  subsequent  aspiratory  action  of  the  uterus  already  mentioned ; 
^  Trans.  New  Jersey  Med.  Soc,  1882.  ^  Am.  Journ.  Obst.,  vol.  xv.  p.  90S. 


lyCMWCITY   Foil    ISSHMISATION.  \  \o 

and    thai     tlic    spcniiato/oa    have    no    pnwi  r    oT  ,-(|(-|)i<ij)iil>i<iii    wliat- 

I'lial  (he  jt't  of  sciiifii  <lncs  soiiK'diiM's  ciitrr  (lii-cctiv  the  utciiiK'  cav- 
ity at  the  tiiiu;  <tf  cniission  is  very  |»r<)l)al)Ic,  altlioiii^li  tlic  i'act  is  not  at 
all  |>roven  hv  such  a  case  as  lliat  iiiciiti<»iic<I  l>y  Addon,'  who  states  that 
Raisch  cxaniiiicil  a  woman  killed  l)\-  licr  husband  in  the  very  act  oi' 
adultci'v,  and  found  semen  in  the  hody  of  the  uterus;-  for  the  presence 
of  the  fluid  may  have  l)een  the  result  of  a  |)i-evious  act  of  intercourse. 
Nor  does  this  view  of  the  process  by  any  means  j)reelude  the  existence 
of,  or  the  necessity  for,  a  seIf-|)ropellin<^  power  on  the  part  of  the  sj)er- 
niatozoa,  hy  which  they  are  enahh.'d  to  pass  upward  when  deposited  in 
the  lower  part  of  the  vagina  within  or  even  upon  the  external  genitals, 
or  to  make  their  way  throuiih  minute  openings  in  any  part  of  the  gen- 
erative passages. 

The  obstacles  which  are  sometimes  overcome  by  spermatozoa  in  their 
onward  journey  are  almost  incredible.  Bozeraan^  relates  a  case  occur- 
ring in  his  own  practice  in  which  there  was  a  continuous  flow  of  urine 
from  the  os  uteri  arising  from  a  vesico-utero-cervical  fistula.  Notwith- 
standing this  advei'se  current  they  reached  their  destination  in  the  cavity 
of  the  uterus,  and  conception,  gestation,  and  a  safe  delivery  followed. 
The  same  writer  mentions  another  case  which  ha[)])ened  in  the  practice 
of  Simon,  in  Heidelberg,  in  which  a  vesico- vaginal  fistula,  complicated 
with  stenosis  of  the  vagina,  had  been  operated  upon  for  incontinence 
of  urine  by  closing  the  mouth  of  the  vagina  about  half  an  inch  behind 
the  meatus  urinarius.  The  operation  was  so  nearly  successful  that  an 
opening  only  the  size  of  a  cambric  needle  was  left.  Strangely  enough, 
the  spermatozoa  passed  through  this  minute  orifice,  traversed  the 
steuosed  vagina,  Avhich  was  then  the  receptacle  of  the  urine  from  the 
bladder,  and  made  their  entrance  through  the  os  uteri  into  the  cavit}' 
of  the  organ.  Conception  and  gestation  followed,  but  resulted  in  the 
death  of  the  patient.  Court}',*  Winckel,^  and  others  have  reported 
similar  cases.  The  former  also  relates  a  case  in  which  the  entire 
uterus  was  removed  bv  Koeberle,  the  ovaries  being;  left.  A  small 
fistula  remained,  forming  a  communication  between  the  vagina  and 
the  abdominal  cavity.  The  woman  subsequently  had  an  abdominal 
pregnancy. 

The  following  case  may  serve  to  illustrate  not  only  the  difficulties 
under  which  eonccjition  may  take  place,  but  also  the  fact  that  gestation 
may  sometimes  contiiuie  under  most  adverse  circumstances: 

'  "  Generation,"  Repertoire  general  des  Sciences  medicale.$,  tome  xiv.  p.  68. 

2  Fallen,  Amer.  Journ.  Obsf.,  1880,  p.  519. 

=»  Xew  York  Med.  Journ.,  Dec.  24,  1884. 

*  Uteru-%  Ovaries^,  and  Fallopinn  Tubes,  |>.  789. 

^  Med.-Chir.  Rund.-ichau,  Dec,  1877- 


446  STERILITY. 

Conception  while   Wearing  an  Intra-uterine  Stem. — Emily   T , 

aged  twenty-five  years,  came  under  my  care  August  21,  1884,  for 
dysmenorrhoea.  She  had  been  married  three  years,  and  had  not  been 
pregnant.  I  found,  on  examination,  a  marked  anteflexion  of  the  cer- 
vix, which  was  conoidal  and  pierced  by  a  typical  pinhole  os.  It  was 
only  with  great  difficulty  that  I  could  introduce  a  probe  into  the  cavity 
of  the  uterus.  On  September  2d,  under  etherization,  I  forcibly  dilated 
the  cervix  to  a  moderate  extent  and  introduced  a  Chambers  divaricating 
stem.  Menstruation  occurred  September  19th,  and  again  October  18th, 
each  time  with  pain,  although  less  than  heretofore.  On  November  1 9th 
a  menstrual  period  commenced  which  lasted  four  days  and  was  painless. 
ISTo  discharge  appeared  dm'ing  December  or  January.  On  January  23, 
1885,  I  examined  her  and  found  that  she  was  undoubtedly  pregnant. 
I  carefully  removed  the  stem,  the  operation  being  attended  by  a  slight 
flow  of  blood  and  mucus.  I  was  fearful  that  an  abortion  would  follow, 
but  there  was  no  untoward  result,  and  a  male  child  was  born  September 
4th,  at  term. 

Coitus  may  be  Impossible.— Besides  the  various  physical  and 
functional  causes  of  male  impotence,  there  are  many  conditions  on 
the  part  of  the  female  which  may  prevent  the  accomplishment  of  the 
sexual  act.     Among  these  may  be  enumerated  the  following : 

Faulty  development  of  the  external  genital  organs ; 

Hypertrophy  of  the  labia ; 

Hypertrophy  of  the  clitoris ; 

Tough  or  hypertrophied  hymen ; 

Atresia  or  stenosis  of  the  vagina ; 

Vaginal  or  vulval  tumors. 

Faulty  Development  of  the  Genital  Organs. — The  abnormities  of 
the  external  sexual  organs  which  may  prevent  intercourse  are  congen- 
ital or  acquired,  and  may  result  either  from  insufficient  or  excessive 
development. 

Among  the  minus  conditions  of  development  are  those  in  which 
there  is  absence  of  some  one  or  more  of  the  vulval  organs.  The 
absence  of  the  clitoris,  hymen,  or  labia,  or  their  rudimentary  growth, 
would  obviously  not  interfere  with  coitus,  provided  the  vagina  were 
sufficiently  pervious.  The  latter  organ  is,  however,  sometimes  com- 
pletely absent  or  defective  in  its  lower  portion,  a  mere  depression  pre- 
senting between  the  labia  niajora,  at  some  portion  of  which  is  found 
the  meatus  urinarius.  In  some  of  these  cases  repeated  attempts  at 
intercourse  have  resulted  in  the  conversion  of  this  opening  into  the 
copulative  organ. 

Sometimes  the  vagina  is  divided  by  a  longitudinal  septum  which  may 
interfere  with  congress  unless  one  or  both  sides  be  sufficiently  capacious 
for  intromission. 


[S< '.  I  /'.  U  'ITY   FOR   ISSI:MIS.  I  770 .V.  |  1 7 

Dr.  v..  I>.  -MapDthor  ivpoits'  the  atse  of  a  lady,  twenty-oi^ht  ywirs 
of  a<i:«',  wlin  icniaincd  storilc  aftor  oi<;ht  ycai-s  <jf  niarriwl  life.  An 
examination  discctverud  the  existence  of  a  nieinhrane  which  en^sed  the 
v:itj:;ina  at  right  angles  three  inches  above  the  oarunculie  niyitifonnes. 
in  this  was  a  circular  hole  one-sixth  of  an  inch  in  diameter,  through 
which  the  sound  parsed  into  a  cavity  above.  The  membrane  was 
excised,  its  removal  disclosing  a  normal  os  and  cervix.  A  glass  dila- 
tor was  worn  for  Hve  weeks.     Pregnancy  ensued. 

Either  as  a  congenital  condition  or  as  a  result  of  subsequent  inflam- 
mation the  labia  majora  are  sometimes  adherent  partially  or  throughout 
their  whole  extent,  an  opening  for  the  escape  of  urine  only  l>eing  left 
and  the  line  of  union  i)eing  marked  by  a  mere  chink  or  furrow. 

Hypertrophij  of  the  Labia. — An  opposite  and  more  numerous  class 
of  ca«e.s  than  the  foregoing  is  that  in  "which  congress  is  prevented  by 
undue  enlargement  of  the  parts  from  excess  of  development  or  as  the 
result  of  disease.  Any  of  the  organs  may  be  thus  affected.  Scanzoni 
states  that  he  knew  a  family  residing  near  Wiirzburg  in  which  the 
mother  and  three  daughters  had  the  labia  excessively  developed  in  a 
manner  similar  to  that  of  the  Hottentots.  He  also  mentions  the  case 
of  a  girl  of  seventeen  at  Prague  in  whom  the  hypertrophied  labia 
formed  a  tumor  larger  than  the  head  of  an  adult  man,  hanging  down 
to  the  middle  of  the  thighs.  About  the  year  1865  I  saw  an  unmar- 
ried woman,  about  twenty  years  of  age,  who  had  an  hypeitrophy  of 
the  left  side  of  the  vulva  involving;  the  o-reater  and  lesser  lalna  through- 
out  their  entire  extent.  It  formed  a  protuberance  larger  than  a  hen's 
egg,  which  would  evidently  have  been  an  impediment  to  intercourse. 
The  enlargement  was  congenital,  and  had  not  perceptibly  increased  for 
many  years.     Surgical  interference  was  declined. 

The  labia  may  also  be  greatly  enlarged  from  elephantiasis  or  from 
the  presence  of  fibrous,  cystic,  or  other  tumors,  so  as  to  prevent  marital 
congress. 

Hypertrophy  of  the  Clitoris. — The  clitoris  has  been  seen  so  exces- 
sively developed  as  to  resemble  the  male  organ,  and  even  to  weigh 
several  pounds,  closing  completely  the  entrance  to  the  vagina. 

Touf/h  or  Hypei-trophied  Hymen. — The  hymen  may  be  so  thick  and 
so  dense  in  structure  as  to  prevent  intercourse.  It  has  been  developed 
in  such  a  manner  as  to  project  in  the  form  of  a  fleshy  tumor  between 
the  labia.^  Yet  it  is  well  known  that  while  such  condition  of  the  hymen 
may  prevent  intromission,  it  is  no  absolute  bar  to  conception,  providing 
the  organ  be  perforate,  for  a  single  drop  of  semen  finding  its  way  into 
the  vagina  of  an  otherwise  healthy  woman  may  result  in  pregnancy. 
The  hymen  has  not  infrequently  been  found  intact  at  the  onset  of  labor, 

1  British  Med.  Joum.,  Sept.  4,  1880. 

*  Boivin  and  Duges,  Traile  des  Maladies  de  P  Uterus. 


448  STERILITY. 

showing  that  its  rupture  is  not  necessary  to  conception.  Usually,  this 
condition  has  been  found  in  unmarried  women  who  have  permitted  lib- 
erties within  what  they  believed  to  be  safe  limits ;  but  it  has  also  been 
observed  in  married  women  from  unusual  rigidity,  great  distensibility, 
or  defective  '^''rility  on  the  part  of  the  husband. 

Atresia  or  Stenosis  of  the  Vagina. — As  already  stated,  the  vagina 
is  sometimes,  though  rarely,  imperforate  in  some  part  of  its  course. 
This  results,  after  puberty,  in  menstrual  retention.  A  more  frequent 
condition,  which  may  be  either  congenital  or  acquired,  is  a  narrowness 
of  some  portion  of  the  canal.  Stenosis  of  the  passage  throughout  its 
entire  extent,  whether  as  a  congenital  condition  or  as  the  result  of  sub- 
sequent cicatrization,  is  exceedingly  uncommon. 

Vaginal  Tumors. — The  vagina  may  be  so  occupied  by  cystic  tumors, 
polypi,  or  inversion  of  the  uterus  as  to  prevent  the  admission  of  the 
male  organ. 

2.  Incapacity  for  Impregnation. 

Impregnation  implies  the  contact  of  a  living  spermatozoon  with  a 
mature  healthy  ovule  at  some  point  beyond  the  uterine  cervical  canal — 
a  requirement  which  may  be  prevented  or  interfered  with,  more  or  less 
completely,  by  many  circumstances. 

Coitus  may  be  Possible,  but  Difficult  or  Painful. — This 
condition,  to  which  the  term  dyspareunia  has  been  given  by  Robert 
Barnes,  is  of  very  great  frequency.  It  may  exist  in  various  degrees, 
from  mere  discomfort  to  such  intensity  of  suiFering  as  to  lead  to  entu'e 
abandonment  of  sexual  attempts.  In  many  of  these  cases  the  woman 
may  be  potentially  fertile,  lacking  only  the  normal  conditions  of  im- 
pregnation. Independently  of  its  influence  upon  fertility,  dyspareunia 
is  a  frequent  source  of  domestic  unhappiness  on  the  part  of  both  hus- 
band and  wife.  It  is  of  obvious  importance,  therefore,  in  every  such 
case  to  seek  for  the  cause  or  causes  which  may  be  operative.  These  are 
numerous,  and  not  always  easily  discovered ;  and,  inasmuch  as  women 
are  usually  reticent  upon  the  subject  unless  interrogated,  the  investiga- 
tion should  be  close  both  in  questioning  and  examination. 

The  following  conditions  are  arranged  for  convenience  under  the 
head  of  dyspareunia,  but  it  should  be  remembered  that  many  of  them 
act  in  other  and  more  certain  ways  in  the  production  of  sterility  than 
by  reason  of  the  difficulty  or  pain  of  intercourse  occasioned  by  them. 
Indeed,  merely  painful  intercourse  does  not  necessarily  involve  sterility, 
and  in  some  instances  only  induces  it  by  limiting  sexual  relations.  The 
causes  of  dyspareunia  are  chiefly  the  following : 

Disproportionate  size  of  the  male  Awkward  sexual  attempts  ; 

and  female  organs ;  Vulvitis; 


INCAPACITY  FOR   7.1//7;/.v;.V.I  770X  449 

Stenosis  of  va^iiKi ;  Oophoritis; 

Vairiiiisiims  ;  IVlvic  iiiflammaton'  exudations; 

\'ai;inal    or    vulvar     liypcriL's-  Urethral  caruiu'Ies ; 

thesia  ;  Fissure  of  tiie  ostium  vaginie  ; 

Uiidiu'  shortness  of  the  va<rina;  Xeuroiiiata  ; 

Lacerations  of  the  eervix  uteri;  Coeeyodynia; 

InHaniiuation  of  the  uterus;  Fissure  of  the  anus; 

Disease  of  the  eervix  uteri  ;  Rectal  uh-er; 

I)isj)laeeinent.s  of  the  uterus ;  Hemorrhoids. 
Prolapsed  ovary ; 

JjUproportlon  of  Male  and  Female  Sexual  Organs. — This  is  some- 
times very  great.  The  ostium  vaginae  may  be  small  or  even  of  normal 
size,  while  the  male  organ  may  be  unusually  develoj)ed.  This  sort  of 
ill-mating  is  occasionally  productive  of  intense  distress.  The  first  sex- 
ual attempts  in  such  cases  are  unsuccessful,  and  if  pei-sisted  in  result  in 
producing  irritation  and  congestion  of  the  structui"es  of  the  female,  and 
thas  induce  additional  elements  of  pain. 

Awkward  Intercourse. — Even  in  the  absence  of  any  disproportion 
a  similar  state  of  irritation  of  the  genitals  may  be  provoked  by  rough 
and  awkward  attempts  at  intercourse.  Usually,  the  normal  vulvar 
mucus  is  present  in  sufficient  quantity  to  so  luljricate  the  parts  that 
penetration  is  effected  "without  injury  to  the  female  organs.  But  where 
it  is  deficient,  and  not  increased  by  sexual  desire  or  by  preliminary  dal- 
liance, much  suffering  may  result. 

Vulvitis. — Inflammation  of  the  external  genital  organs  mav  arise 
from  varioas  irritating  causes,  and  declare  its  presence  by  tumefaction, 
heat,  tenderness,  and  a  ])uruing  sensation.  These  symptoms  are  aggra- 
vated by  the  chafing  produced  by  walking  or  other  exercise.  Fat 
women  are  especially  liable  to  an  erythema  from  the  excessive  friction 
to  which  the  parts  are  subjected.  This  may  proceed  to  involvement  of 
the  deeper  tissues,  and  finally  result  in  glandular  or  cellular  inflamma- 
tion and  abscess.  It  may  likewise  extend  to  the  vagina,  urethra,  and 
inner  surfaces  of  the  thighs.  Intercourse  in  such  cases  is  attended  by 
great  suffering,  and  is,  at  the  same  time,  most  prejudicial. 

Stenosis  of  the  Vagina. — Either  as  a  congenital  defect,  as  the  result  of 
injury,  the  action  of  chemical  irritants,  or  as  a  sequel  of  exanthematous 
diseases,  the  vagina  may  be  so  greatly  contracted  as  to  cause  painful 
intercourse  or  prevent  it  wholly. 

Vaginismus. — By  this  term  is  understood  a  condition  of  the  parts 
about  the  hymen  and  vaginal  entrance  which,  in  its  more  marked  forms, 
results  in  extreme  suffering  whenever  any  attempt  is  made  to  effect  pene- 
tration, or  even  to  touch  the  parts.  The  constricting  muscles  around 
the  mouth  of  the  vagina  are  thrown  into  a  state  of  spasmodic  action  so 
Vol.  I.— 29 


450  STERILITY. 

great  as  to  occlude  the  entrance,  and  the  finger  when  introduced  seems 
held  as  though  it  were  in  a  vise.  In  some  instances  an  apparent  cause 
for  this  condition  may  be  observed  in  patches  of  redness,  erosion,  or 
neuromata  about  the  vestibule  or  the  carunculse  myrtiformes,  but  in 
others  nothing  whatever  can  be  detected  to  which  the  phenomenon 
can  be  referred.  Usually,  the  seat  of  vaginismus  is  at  or  near  the 
vaginal  entrance.  Dr.  H.  R.  Storer  has  called  attention,  however, 
to  the  fact  that  there  also  exists  a  second  variety  which  is  seated 
higher  up,  and  which,  depending  upon  violent  vaginal  spasm,  expels 
at  once  and  forcibly  everything  deposited  there;  for  example,  the 
spermatic  fluid.  This  he  was  enabled  to  remedy,  and  so  cure  ster- 
ility, by  resort  to  a  simple  ring  pessary,  which  gave  the  canal  some- 
thing to  grasp. 

Vulvar  or  Vaginal  Hypercesthesia. — A  similar  condition  to  the  fore- 
going, characterized  by  extreme  sensitiveness  of  the  vulva  and  vagina, 
exists  sometimes  without  the  presence  of  the  spasmodic  constriction 
which  constitutes  the  essential  feature  of  vaginismus.  Usually,  the 
symptom  is  wholly  subjective,  and  can  only  be  attributed  to  some 
occult  condition  of  the  nerves  supplying  the  parts. 

Undue  Shortness  of  the  Vagina. — In  some  cases  the  vagina  is  unduly 
short,  being  not  more  than  two  or  three  inches  in  length,  and  neces- 
sarily maintaining  the  cervix  uteri  in  a  position  abnormally  near  the 
vulva.  Unless  great  care  on  the  part  of  the  husband  be  exercised  the 
parts  soon  become  tender  and  dyspareunia  results.  According  to 
Courty,^  this  condition  of  the  vagina  may  be  productive  of  barren- 
ness in  another  way — namely,  by  favoring  the  formation  of  a  copula- 
tive sac  outside  of  the  axis  of  the  uterine  canal,  and  consequent  mal- 
direction  of  the  semen. 

About  twelve  years  ago  I  examined  a  sterile  woman,  thirty-two  years 
of  age,  who  had  been  married  five  years  and  who  had  never  menstru- 
ated. Her  health  had  always  been  excellent.  The  mammae  were  large 
and  the  external  genital  organs  perfectly  developed.  She  confessed  to 
having  both  sexual  desire  and  enjoyment.  The  vagina  w^as  not  more 
than  two  inches  in  depth,  and  was  very  narrow,  especially  at  the  upper 
portion,  which  terminated  in  a  flat,  button-like,  non-projecting  hard- 
ness about  a  quarter  of  an  inch  in  diameter,  situated  at  the  proper  site 
of  the  vaginal  portion.  I  was  unable  to  detect  any  opening  in  it. 
With  a  male  sound  in  the  bladder  and  a  finger  in  the  rectum  there 
was  felt  a  firm  body  an  inch  long  and  half  an  inch  wide  occupying 
the  place  of  the  uterus.     No  ovaries  could  be  felt. 

Lacerations  of  the  Cervix  Uteri. — These  do  not  usually  occasion  pain- 
ful intercourse,  although  I  have  seen  several  cases  in  which  there  was 
no  other  apparent  cause   for  the  symptom,  and  in  which  the  latter 

^  Uterus,  Ovaries,  and  Fallopian  Tvhes,  p.  790. 


iNCArAciTV  FOR  iMi'iii:<;sATiny.  .j.-ji 

promptly  (lisapju'aivd  alter   the   iiijuiy  was  repaired.     This  eomlilioii 
may  also  pivvi'iit   rruitfiiliiess   hy  iii(liieiii«r  cirly  al)nrtii)ii. 

UUrinc  Injhunnutfion. — The  iiillaiiiiiiatory  alleetioiis  of  the  iil<riis 
are  almost  always  pi-oduetixc  ol"  pain  and  tondcrness,  especially  in  the 
lower  seuineiit  ol"  the  or^aii,  which  is  likewise  increased  in  bulk  and 
lower  in  tlii'  pelvis,  and  hence  more  suhjeet  to  ineehanieal  injniy 
dnrini;-  coitus. 

J)is(<(sc  of  the  Ccrrix  Utn-i. — Diseased  conditions  of  the  cervix  uteri 
Avhich  involve  loss  of  substance  or  other  chany;e  of  structure  sometimes 
produee  |)ain  and  undue  sensitiveness  of  the  parts.  Not  always,  cer- 
tiiinly,  for  in  many  cases  extensive  erosions  and  hvi)erj)lastic  conditions 
of  the  cervix  ji;ive  rise  to  no  complaint  whatever.  This  is  ntttablv  true 
in  cervical  e})ithelioma  j)rior  to  the  involvement  of  the  surnjundiug 
connective  tissue. 

DispUu'i'iiivntH  of  the  Uterus. — Certain  malpositions  of  the  uterus  occa- 
sion dyspareunia  by  occupying  the  vagina,  as  occurs  in  inversion  and 
prolapsus.  Ordinarily,  however,  the  forward  and  backward  displace- 
ments, including  flexions,  act  only  indirectly  througli  the  congesticju  and 
consequent  tenderness  of  the  organ  induced  by  its  abnormal  position  and 
shape. 

Prolapse  of  the  Omrij. — Whenever  an  ovary  is  prolai)sed  in  any 
considerable  degree  it  commonly  becomes  excessively  tender.  It  is 
likewise  usually  enlarged.  It  occupies  a  position  more  or  less  low  in 
Douglas's  space,  where  it  is  exposed  to  pressure  during  defecation  and 
to  impingement  of  the  male  organ  during  intercourse.  Dyspareunia 
from  this  cause  is  in  some  instances  very  great — not,  however,  nnless 
the  prolai)sed  organ  be  the  seat  also  of  inflammation  or  neuralgia.  I 
have  in  a  few  instances  found  one  or  both  ovaries  occupying  the  lower 
portion  of  the  vagino-rectal  cul-de-sac  M'ithout  giving  anv  evidence  of 
undue  sensitiveness,  or,  indeed,  producing  any  uncomfortable  symptom. 

Oophoritis. — When  the  ovary  is  inflamed,  whether  it  be  in  place  or 
prolapsed  and  whether  the  inflammation  be  acute  or  chronic,  the  oriran 
becomes  extremely  sensitive,  and  dyspareunia  from  this  cause  is  usuallv 
of  a  most  intense  character. 

Pelvic  IiiffaiiDiiafori/  ExurJafions. — Inflammatory  exudations  the  result 
of  pelvic  cellulitis  and  peritonitis  constitute  frequent  sources  of  painful 
congress,  and  without  careful  examination  they  may  be  easily  overlooked. 
Sometimes  the  tenderness  will  be  confined  to  a  single  spot  of  hardness 
not  larger  than  a  ])ca  on  one  or  other  side  of  the  uterus.  Usually, 
however,  in  cases  of  this  character  the  pain  results  either  from  the 
stretching  of  adhesions  which  interfere  Avith  the  normal  mobilitv  of  the 
uterus,  or  from  deposits  in  the  tissues  about  the  ovaries,  Falh^pian  tubes, 
and  in  Douglas's  space. 

Urethral  Caruncles. — These  consist  of  proliferations  of  the  nmcous 


452  STERILITY. 

membrane  within  or  near  the  urinary  meatus,  and  form  an  occasional 
cause  of  both  painful  intercourse  and  dysuria.  These  bodies  vary  in 
size  from  that  of  a  pin's  head  to  a  large  raspberry,  and  are  some- 
times the  seat  of  excessive  sensibility.  A  similar  condition,  but  with- 
out elevation  of  the  surface,  is  one  in  which  patches  of  mucous  mem- 
brane in  various  parts  of  the  vestibule  become  denuded  of  epithe- 
lium, and  are  exquisitely  painful  under  the  slightest  touch.  These,  as 
well  as  the  smaller  carunculse,  can  only  be  detected  by  carefid  inspection. 

Fissure  of  the  Ostium  Vaginae. — A  slight  laceration  may  be  produced 
at  the  first  sexual  attempts,  and  unless  the  parts  are  permitted  to  rest 
sufficiently  long  for  healing  to  take  place  a  fissure  similar  to  those 
sometimes  seen  at  the  anus  may  remain  and  become  the  seat  of  intense 
pain. 

Neuromata  of  the  Genital  Tract. — These  are  commonly  situated  on 
some  part  of  the  vulva  and  in  the  vagina.  The  following  is  the  only 
case  of  this  character  with  which  I  have  met : 

Dyspareimia  Cured  by  the  Removal  of  a  Small  Neuroma  of  the  Vagi- 
nal Wall. — A  few  years  ago  I  was  consulted  by  a  gentleman  in  refer- 
ence to  dyspareunia  on  the  part  of  his  wife.  They  had  been  married 
four  years  and  were  childless,  although  there  was  a  history  of  two 
doubtful  abortions  at  five  or  six  weeks.  During  the  past  year  inter- 
course had  become  gradually  more  and  more  painful,  and  had  not  been 
attempted  for  several  months.  The  seat  of  pain  was  just  within  the 
entrance  of  the  vagina.  An  inspection  of  the  vulva  revealed  nothing 
abnormal.  The  introduction  of  the  finger  was  attended  by  pain  which 
the  patient  located  on  one  side  about  an  inch  from  the  vaginal  orifice. 
Pressure  or  slight  friction  upon  this  spot  caused  intense  pain.  There 
was  no  spasm.  When  I  avoided  the  spot  no  pain  was  produced.  Sep- 
arating the  parts  antero-posteriorly  with  a  bivalve  speculum,  I  brought 
the  tender  space  into  view.  There  was  neither  swelling  nor  redness 
apparent :  it  looked  precisely  like  the  opposite  side.  With  the  tip  of 
a  uterine  sound  I  made  pressure  in  the  neighborhood  of  the  seat  of 
pain,  and  suddenly  the  patient  started  and  exclaimed,  "  That's  the 
place !"  Thus  directed,  I  could  detect  a  slight  elevation  of  the  surface 
caused  by  a  minute  tumor  not  larger  than  a  grape-seed.  Passing  a 
small  hook  beneath  and  raising  it,  I  excised  it  with  scissors.  Immedi- 
ately, while  the  cut  surface  was  yet  bleeding,  I  could  press  the  sound 
into  the  spot  without  evoking  the  former  pain.  The  sides  of  the  cut 
were  brought  together  with  a  stitch,  and  soon  united.  The  cure  was 
complete. 

CoGcyodynia,  etc. — In  addition  to  the  causes  of  painful  intercourse 
already  mentioned,  there  are  othei'S  which  do  not  have  their  seat  in  the 
genital  organs,  but  in  neighboring  structures,  and  hence  the  latter 
should  not  be  omitted  from  the  investio-ation.     Among  these  the  more 


INCA VArlTY   !•')  11    IM 1  'li !■:( / A'.  1 1 7 ON.  4 ->;} 

frequent  are  coeeyndynin,  lissiire  of  tlie  ami>,  reefal  nicer,  mikI   licnMH- 
rliuids. 

thtrifodi/iiia  is  the  tenn  used  to  desijrnatc  a  paiiiiiil  st:ite  ol"  the  |);irts 
in  tli(>  iUM't!:lil)()rlii)()(i  of  the  coeeyx.  It  is  usually  j)urely  neural;;ie  in 
character,  althou«;h  souietinies  depeudeut  uj)ou  structiu-al  disease  of  the 
hoiie,  the  pci-iosteuiM,  or  the  siu'roiiiidiiin-  parts.  When  j)resent,  the 
pain  is  excited  or  a«;<iravated  i)y  any  inov<'nieut  of  the  ])art,  as  occiu's 
iu  risiiiji;  from  the  sittiui:;  posture,  duriu<>;  defecation,  or  in  coj)ulation. 

Fissure  of  the  Anus. — Cracks  or  fissures  at  the  anus  are  occasionally 
a  source  of  very  considerable  pain  durinii;  and  after  intercourse.  TIm-v 
are  soinetiines  so  sliii;ht  as  to  escape  detection  except  by  a  most  careful 
examination.  Their  presence  may  be  suspected  when  defecation  is  fol- 
lowed by  habitual  pain  or  aehino-,  especially  if  at  times  there  is  observed 
also  the  discharge  of  a  droj)  or  two  of  blood. 

In'itnble  Ulcer  of  the  Rectum. — This  condition,  like  the  preceding, 
can  only  be  determined  by  a  rectal  examination. 

Pahiful  Heiiu)rr]ioi(h. —  Hemorrhoids  Avhich  have  become  inflamed 
are  sometimes  extremely  painful,  and  may  then  constitute  a  cause  of 
dysparcunia. 

The  Semixal  Fluid  may  xot  coxtain  axy  Spermatozoa  ;  on, 

THE  LATTER  MAY  BE  DeAD  OR  POSSESS  DeFICIEXT  VITALITY  WIIEX 

Deposited  ix  the  Yagixa. — The  pathological  changes  Avhich  may 
take  place  in  the  seminal  fluid,  and  the  conditions  of  the  testicles  which 
result  in  the  absence  of  spermatozoa  or  iu  their  scantiness  or  feeble 
vitality,  are  not  known.  Whatever  they  may  be,  they  are  certainly  not 
usually  capable  of  detection. 

Male  Sterility  depending  upon  Ai^pevmatism. — In  Xoveml^er,  1883,  a 
lady,  thirty  years  of  age,  Avho  had  been  married  seven  years  and  Avho 
had  never  conceived,  consulted  me  in  reference  to  her  barrenness.  Her 
history  gave  no  clue  as  to  its  cause.  Her  health  Avas  perfect ;  every 
function  was  properly  performed.  Her  husband  was  four  years  older 
than  she,  healthy,  affectionate,  and  sexually  vigorous.  Between  them 
there  Avas  no  incompatibility  of  temperament.  A  careful  examination 
of  the  generative  organs  revealed  no  abnormity  of  conformation,  con- 
dition, or  position. 

In  a  subsequent  interview  with  the  husband  I  learned  that  prior  to 
his  marriage  his  habits  had  been  rather  irregular,  and  that  at  the  age 
of  twenty  he  had  contracted  a  gonorrhoea  which  resulted  in  tenderness 
and  swelling  of  both  testicles.  At  the  time  of  my  examination  I  could 
detect  nothing  wrong  with  any  of  the  genital  organs.  I  suggested  an 
examination  of  the  semen,  and  a  few  days  afterwai'd  placed  under  tlie 
microscope  a  portion  of  the  fluid  taken  from  the  vagina  of  the  wife 
within  an  hour  after  coitus.  Xot  a  spermatozoon  could  be  found. 
This   examination   was    repeated    after   a   fortnight's    abstinence   from 


454  STERILITY. 

intercourse  with  the  same  negative  result.  The  man  was  absolutely- 
sterile. 

It  would  seem  that  spermatozoa  belonging  to  the  same  emission  vary 
greatly  in  their  power  to  resist  destructive  influences.  The  observations 
of  Sims,  Haussmann,  and  others  show  that  the  great  majority  of  them 
perish  in  the  vagina  within  a  very  few  hours  after  their  deposition,  and 
that  those  which  retain  their  vitality  cease  to  move  after  twelve  hours. 
Some  are  motionless  from  the  first.  Those  which  reach  and  enter  the 
cervical  canal  live  much  longer.  When  the  external  os  uteri,  the  cer- 
vical canal,  and  the  secretions  were  normal,  living  spermatozoa  were 
found  in  the  passage  seven  and  a  half,  and  by  Percy  eight  and  a  half, 
days  after  coitus. 

Healthy  Speematazoa  aftee  being  Deposited  in  the 
Vagina  may  be  Destroyed  befopvE  reaching  the  Cervical. 
Canal. — The  most  frequent  cause  of  the  untimely  death  of  sperma- 
tozoa is  the  acid  nmcus  of  the  vagina.  The  degree  of  acidity  varies 
greatly  in  different  women,  and  in  the  same  woman  at  different  times. 
Not  infrequently,  a  decidedly  sour  odor  may  be  detected  during  the 
introduction  of  the  speculum,  and  the  mucus  at  such  times  will  intensely 
redden  litmus-paper.  Spermatozoa  perish  immediately  in  such  a  fluid. 
This  condition  is  thought  by  some  to  be  more  frequent  in  blonde  women 
with  red  complexions  than  in  brunettes. 

On  the  contrary,  the  slightly  alkaline  mucus  of  the  interior  of  the 
uterus  is  favorable  to  the  vitality  of  the  spermatozoa,  as  already  shown. 
But  when  the  uterine  secretions  are  altered  by  disease  they  likewise 
cause  their  speedy  death.  Levy  ^  of  Munich  made  microscopical  exami- 
nations to  determine  the  condition  of  the  spermatozoa  at  different  inter- 
vals after  coitus  in  60  women  who  were  sterile.  Catarrh  of  the  uterus 
was  present  in  57  of  them.  In  every  case  the  number  of  spermatozoa 
found  within  the  cavity  of  the  uterus  was  small,  and  they  had  all 
become  motionless  at  the  end  of  five  hours.  In  healthy  women  the 
movements  continued  at  least  twenty-six  hours. 

In  408  cases  of  sterility  collected  by  Kammerer  ^  uterine  catarrh  was 
present  in  342.  That  the  condition  is  a  very  common  one  among 
sterile  women  there  can,  therefore,  be  no  doubt;  and  Sims  and  others 
have  stated  their  belief  in  its  great  frequency  as  a  causative  agent. 
But  it  seems  to  me  that  more  importance  has  been  attributed  to  it  in 
this  respect  than  facts  warrant.  We  know  that  women  may  conceive 
when  the  vagina  is  constantly  bathed  with  the  offensive  discharge  from 
carcinoma  of  the  uterus,  even  when  it  is  so  acrid  as  to  cause  removal  of 
epithelium  and  epidermis.  It  is  likewise  well  known  that  a  continually- 
leaking  vesico-vaginal  fistula  is  no  bar  to  conception.     Hence  I  can- 

^  Obstetrical  Journal  of  Great  Britain  and  Ireland,  vol.  vii.  p.  471. 
*  Transactions  New  York  Academy  of  Medicine,  part  vii.  of  vol.  iii. 


INCAPACITY  FOR  IMPRKf! NATION.  455 

not  thiiilx  llial  the  oi'diiiary  catai-rlial  (liscliar^c  froiii  llic  "(.nitals  is  so 
^rcatlv  inimical  to  the  lite  of  tlic  sptTinato/cta  as  lias  been  supposed.  It 
is  ti'iu!  lliat  the  siip|)i'essi()H,  or  even  tlie  (liniiniition,  ot"  a  leneorrii«eal 
(liscliari;'e  may  In- (piiekly  Inllowcd  Wy  impreguation,  hnt  this  fact  does 
not  prove  that  the  presence  (tfthe  leucoiTJKea  was  the  eansc;  of  the  j)re- 
eedinti'  infertility,  l^^)r,  heiiii;-  only  a  symptom  of  strnctnral  disease 
which  nnlittcd  the  nterns  for  fni'iiishini;-  a  siiitaMc  nidtis  for  the  u'crm, 
the  ahateiuent  of  the  dischar<;'e  may  be  a  consecpience  of  removal  of  the 
lesion  which  prodneed  it.  Impregnation  pi-obably  occurs  much  more 
frequently  in  these  eases  than  is  supposed,  but  owing  to  the  defect  in 
the  nesting  and  developmental  processes  very  early  abortion  habitually 
takes  place. 

Biegel  has  found  that  all  of  the  following  agents  are  destructive  of 
spermatozoa:  water,  saliva,  sour  milk,  alcohol,  ether,  chlorofjrm,  crea- 
sote,  tannin,  acetic  acid,  mineral  acids,  metallic  salts,  ethereal  oils. 

Semen  may  be  Deposited  in  the  Vagina  and  prevented 

FROM   OCCUPYING  A  POSITION    FaYORABLE   TO    FECUNDATION. — The 

emitted  semen  normally  forms  a  pool  in  the  upper  posterior  portion  of 
the  vagina,  into  which  the  cervix  uteri  settles  after  intercourse.  Every 
facility  is  thus  afforded  for  the  entrance  of  spermatozoa  into  the  uterine 
canal.  Various  conditions  may,  however,  to  a  greater  or  lesser  degree, 
interfere  with  this  disposition  of  the  seminal  fluid.  Among  these  may 
be  enumerated  the  following :  absence  of  the  vaginal  portion ;  conical 
elongation  of  the  vaginal  portion ;  unequal  size  of  the  uterine  lips ; 
cervical  hypertrophy ;  laceration  of  the  cervix  uteri ;  uterine  flexions 
and  versions ;  prolapse  and  inversion  of  the  uterus ;  abnormal  attach- 
ment of  cervix  to  vagina. 

Semen  may  be  favorably  Deposited  in  the  Vagina,  but 
unable  to  advance  to  the  Cavity  of  the  Uterus. — The 
abnormal  conditions  which  may  act  as  impediments  to  the  progress  of 
the  spermatozoa  are  chiefly  as  follows : 

Atresia  or  stenosis  of  the  os  uteri  and  cervical  canal  j 

Uterine  flexions  and  displacements ; 

Tumors  of  the  uterus ; 

Uterine  polypi ; 

Mucous  plug  in  os  and  cervix  uteri ; 

Hypertrophied  cervical  rugfe; 

Deformity  of  uterine  cervix  and  labia. 

Atresia  or  Stenosis  of  the  Os  mid  Cervix  Uteri. — Atresia — that  is, 
complete  closure  of  the  os  uteri  or  cervical  canal — is  absolute  in  its 
power  to  prevent  conception.  Occasionally  the  os  uteri  is  found 
wholly  imperforate,  either  as  a  congenital  defect  or  as  the  result  of 
adhesive  inflammation.  Complete  congenital  closure  of  the  os  uteri 
is  very  rare :  the  acquired  form  may,  however,  occur  from  cicatriza- 


456  STERILITY. 

tion  after  inflammation  produced  by  injuries  during  parturition,  sur- 
gical operations  upon  the  parts,  or  the  application  of  powerful  caustics 
to  the  interior  of  the  canal.  In  these  cases  only  a  limited  portion  of 
the  canal  is  usually  involved. 

Not  only  is  the  condition  a  barrier  to  the  entrance  of  spermatozoa, 
but  also  to  the  exit  of  mucus  and  blood.  Hence,  except  in  the  case 
of  an  infantile  or  non-secreting  uterus,  it  would  be  attended  by  recur- 
ring pains,  and,  if  of  sufficiently  long  standing,  by  enlargement  of  the 
uterus  from  retention. 

Stenosis,  or  a  narrowing  of  the  cervical  canal,  may  occur  at  either  the 
external  or  internal  os  or  at  any  portion  of  the  passage.  The  canal  of 
the  cervix  should  be  considered  physiologically  normal  when  it  is  able 
to  perform  its  functions  with  comparative  ease  and  painlessness.  This 
it  may  do  although  of  greater  length,  lessened  calibre,  and  more  tortuous 
di^^ection  than  usual.  It  is  obstructive  only  when  it  does  not  readily 
transmit  blood  or  mucus  from  the  uterine  cavity  or  permit  the  ingress 
of  spermatozoa.  A  normal  cervical  canal  is  hence  a  relative  and  not  an 
absolute  thing,  and  cannot  be  determined  simply  by  measurements. 

Whatever  may  be  the  method  or  mechanism  by  which  spei'matozoa 
pass  through  the  cervical  canal — whether  by  a  suction  process  on  the 
part  of  the  female  or  an  inherent  power  of  progression  in  the  sper- 
matozoa— it  is  certain  that  the  latter  are  capable  of  advancing  from  the 
vagina  inward  through  a  much  smaller  space  than  is  necessary  for  the 
transmission  of  blood  and  mucus.  Hence  a  woman  may  have  obstruct- 
ive dysmenorrhoea  and  yet  not  be  sterile.  Indeed,  except  in  complete 
closure  it  is  doubtful  whether  mechanical  impediments  to  the  union  of 
the  spermatazoa  and  ovule  play  so  important  a  part  as  has  commonly 
been  supposed,  A  constriction  of  the  cervical  canal  to  the  size  of  the 
minute  openings  of  the  uterine  extremities  of  the  Fallopian  tubes  would 
be  regarded  as  very  extreme,  and  yet  the  spermatozoa  pass  through  the 
latter  without  difficulty. 

It  should  be  remembered,  too,  that  there  are  usually  other  factors 
present  than  the  mere  narrowing  of  the  canal.  When  the  constriction 
is  at  the  os  externum,  the  secretions  of  the  uterus  are  jDrevented  from 
escaping  and  the  canal  above  is  expanded  and  filled  with  a  glairy, 
tenacious  mucus,  which  may  be  seen  to  escape  sometimes  in  large 
quantity  by  the  introduction  and  separation  of  a  pair  of  forceps.  There 
is  in  these  cases — whether  as  cause  or  effect — a  follicular  cervical  endo- 
metritis, the  cystic  enlargements  assisting  to  impede  the  exit  of  the 
mucous  secretion  and  constituting  an  obstacle  to  the  ingress  of  the 
sperm. 

I  do  not  by  any  means  deny  that  even  a  moderate  degree  of  constric- 
tion may  hinder,  to  some  extent,  the  passage  of  spermatozoa,  or  that, 
when  the  narrowing  is  great,  there  is  commonly  both  dysmenorrhoea 


iNCAPAriTY  FOR  iMrm:ay.\TioN.  A'u 

and  sterility  ])rosent ;  hut  it  is  well  kiKtwii  that  in  such  oases,  while 
dihitation  may  he  elVectiNc  in  wholly  relieving  the  (lysineiiorrhu'a,  it 
is  more  likely  to  fail  iliaii   to  succeed  in  removing  the  sterility. 

Flexions  and  Disp/acnnmLs  of  the  Uterus. — These  do  not  necessarily 
determine  sterility,  although  conception  may  he  difllicult  where  they 
exist.  1  have  known  many  instances  in  which  there  existed  a  flexion 
so  acute  as  to  })revent  the  introduction  of  the  sound  and  to  occasion 
severe  dysmenorrhoea,  and  yet  conception  took  place  shortly  after  mar- 
riage w^ithout  the  subject  having  undergone  any  treatment  whatever. 
Nevertheless,  when  flexion  is  so  extreme  as  to  bring  the  ©imposing  ute- 
rine walls  into  firm  contact,  there  would  manifestly  be  interference  with 
the  progression  of  spermatozoa.  In  114  cases  of  sterility  reported  by 
Biegel  in  which  the  causes  seemed  evident  there  was  some  form  of  dis- 
placement in  40 — that  is,  35  per  cent.  In  26  there  was  version,  in  12 
flexion,  and  in  2  prolapse.  Mayer's  272  cases  show  60  of  anteflexion, 
37  of  retroflexion,  35  of  anteversion,  3  of  retroversion — nearly  50  per 
cent.  In  Kammerer's  table  of  408  cases  ^  there  were  of  anteflexion,  83  ; 
retroflexion,  71  ;  descensus,  8  ;  prolapse,  1 — nearly  40  per  cent.  In  72 
cases  observed  by  myself  (p.  463)  there  were  16  of  anteflexion,  9  of 
retroflexion,  3  of  anteversion,  7  of  retroversion — 40.3  per  cent. 

It  would  appear  from  these  tables  that  displacements  of  the  uterus 
constitute  a  very  frequent  and  important  feature  in  the  causation  of 
sterility ;  and  doubtless  such  is  the  fact.  But  what  has  been  stated  in 
regard  to  uterine  catarrh  is  equally  applicable  here — namely,  that  in  all 
or  nearly  all  cases  of  chronic  displacement  there  are  present  other  com- 
plicating morbid  conditions  to  which  the  infertility  may  be  ascribed 
with  as  much  plausibility  as  to  the  malposition. 

Tumors  of  the  Uterus. — Fibro-myomata,  especially  when  located  in 
the  cervix,  are  sometimes  so  situated  as  to  prevent,  or  at  least  greatly 
obstruct,  the  passage  of  semen  through  the  cervical  canal.  When  they 
are  small  and  occupy  the  lower  portion  of  the  cervix,  they  do  not 
usually  produce  either  pain  or  menorrhagia,  and  may  hence  be  readily 
overlooked  unless  their  possible  presence  be  taken  into  consideration. 
Such  tumors  may  distort  the  uterine  cavity  and  cause  catarrh  and 
thickening  of  the  lining  membrane,  and  thus  act  both  mechanically 
and  chemically. 

Submucous  tumors  of  the  uterus  may  prevent  conception  by  the  men- 
orrhagia -which  they  usually  cause,  the  profuse  flow  of  blood  carrying 
the  ovule  away  from  the  uterine  cavity.  Winckel  reports'  that  the 
most  common  complication  of  uterine  fibroids  found  by  him  was  the 
existence  of  adhesions  between  the  uterus  and  neighboring  organs,  these 
being  present  in  21  out  of  34  cases  examined. 

Uterine  Polypus. — Polypi  of  the  uterus  which  wholly  or  partially 

'  Loc.  cit.  ^  Med.-Chirurgical  Rundschau,  Dec,  1877, 


458  STERILITY. 

obstruct  any  part  of  the  cervical  canal  may  act  as  an  impediment  to 
the  onward  movement  of  spermatozoa.  If  a  polypus  becomes  strangu- 
lated and  gangrenous,  as  sometimes  happens,  the  resulting  acrid  dis- 
charge may  be  destructive  to  the  vitality  of  the  spermatozoa. 

Mucous  Plug  in  Os  and  Cervix  Uteri. — The  firm,  dense  mass  of 
mucus  which  is  found  so  frequently  filling  the  cervical  canal  and  hang- 
ing from  the  os  uteri  is  a  mechanical  obstacle  to  the  ingress  of  sperma- 
tozoa. It  is  a  result  of  chronic  cervical  endometritis,  and  is  removable 
only  with  the  greatest  difficulty.  Haussmann  found  an  abundance  of 
spermatozoa  entangled  in  one  of  these  mucus  masses.  Usually,  it  is 
washed  away  by  the  menstrual  discharge,  and  conception  may  occasion- 
ally take  place  when  insemination  occurs  shortly  after  a  menstrual 
period  and  before  the  plug  reappears. 

Hypertrophied  Cervical  Rugm. — Chronic  inflammation  of  the  cervix 
may  act  injuriously  also  by  producing  hypertrophy  of  the  cervical  rugse, 
and  causing  an  abnormal  degree  of  coaptation  of  the  opposing  surfaces. 

Deformity  of  the  Uterine  Cervix  and  Labia. — Various  malformations 
of  the  vaginal  portion,  involving  its  length,  thickness,  shape,  and  direc- 
tion, may  make  impregnation  impossible,  or  at  least  highly  improbable. 
It  may  be  so  greatly  hypertrophied  in  its  longitudinal  direction  as  to 
bring  the  os  uteri  almost  to  or  quite  beyond  the  vulva,  the  fundus  of 
the  organ  remaining  in  its  proper  place.  Sterility  always  accompanies 
this  condition.  Or  the  labia  may  be  wholly  absent,  the  os  uteri  pre- 
senting, instead  of  a  horizontal  fissure,  a  circular  orifice  situated  at  the 
apex  of  the  cervix.  This  opening  is  sometimes  so  small  as  to  be  invisi- 
ble to  the  naked  eye  and  capable  of  admitting  only  the  smallest  probe. 
This  condition  of  the  os,  termed  "  pinhole,"  situated  at  the  extremity 
of  a  conoidal  cervix,  is  a  not  infrequent  anomaly.  Here  both  the  nar- 
rowness of  the  OS  and  the  shape  of  the  cervix  are  causes  both  of  dys- 
menorrhcea  and  sterility.  A  semilunar  form  of  the  os  is  likewise 
unfavorable  to  conception. 

Another  variety  of  labial  deformity  is  that  in  which  one  lip,  usually 
the  anterior,  projects  beyond  and  overlaps  the  other.  In  this  condition 
the  OS  is  closed  to  ingress  from  the  vagina,  although  no  eifective  obstacle 
may  be  offered  to  the  passage  of  menstrual  blood  from  within  outward. 

3.  Incapacity  for  Ovulation. 

Heretofore,  I  have  considered  the  conditions  which  may  interfere 
with  the  elaboration  of  capable  spermatozoa  and  their  access  to  the 
interior  of  the  uterine  cavity.  Their  existence  is,  with  scarcely  an 
exception,  ascertainable  by  touch  or  sight.  There  are  other  circum- 
stances, however,  which  are  equally  unfavorable  to  fecundation,  and 
which  are  almost  entirely  beyond  our  means  of  investigation,  and  also 


ixrAp.irrrv  for  ovriArroy.  450 

uii:mu'nal)le  to  curative  trcatiiR'nt.  I  ivfci*  (o  tlictsc  which  j)r(!Vont  the 
ilevL'lo|)iueiit  and  separation  of  a  mature  ovule  and  its  transmission  to 
the  uterine  cavity.  They  inchide  the  al)normities  of  development  and 
the  oriijanic  and  functional  tliseases  of  the  (jvaries  and  Fallopian  tuijes. 
Tiiey  ai'c  not  accessible  to  our  sense  of  si};ht,  and  onlv  imju'i-feetlv,  if 
at  all,  to  toiicli.  Hence  their  diaj^nosis  must  always  be  doubtful  duriiij^ 
lif,'. 

TiiH  OvuLK  MAV  NOT  Matimik. —  It  is  probable  that  many  ovules 
escape  from  the  Graafian  follicles  in  an  immature  state,  and  are  inca- 
j)ablo  of  impreijnation.  Doubtless,  the  function  of  ovulation  is  more 
perfectly  and  more  fretpiently  performed  in  some  women  than  in  others. 
This  fact  may  explain  Avhy  it  is  that  some  women  conceive  with  more 
or  less  rei2;ularity  every  fifteen  or  eighteen  months,  and  others  only  at 
intervals  of  several  years;  why  thousands  of  sexual  connections  should 
be  barren,  and  a  single  one  under  apparently  similar  circumstances  be 
fruitful ;  and  why  in  some  cases  pregnancy  should  occur  only  after 
many  years  of  unfruitful  married  life,  the  observable  conditions  being 
apparently  unchanged.  We  know  absolutely  nothing  of  the  possible 
pathological  changes  in  the  ovule  which  may  hinder  its  ripening  or 
render  it  incapable  of  fructification. 

Disease  of  the  Ovaries. — It  is  not  difficult  to  understand  that  any 
diseased  state  affecting  the  nutrition  of  the  ovaries  might  result  in  the 
production  of  diseased  or  defective  ova,  and  yet  it  is  not  unusual  for 
women  whose  ovaries  are  studded  with  cysts  or  otherwise  diseased  to 
conceive  and  give  birth  to  healthy  children. 

Abnonnal  States  of  the  Blood. — In  extreme  angemia  conception  does 
not  take  place,  the  defective  condition  of  the  blood  being  probablv  the 
cause  of  immaturity  of  the  ova.  On  the  other  hand,  conception  is  rare 
also  in  women  who  present  undue  fatty  accumulation,  although  their 
blood  may  be  perfectly  normal  in  quality. 

Tubercle,  Syphilis,  Gonorrhoea. — The  cachexise  of  tubercle,  the  poi- 
sons of  syphilis  and  gonorrhoea,  or  great  general  debility  resulting 
from  any  other  cause  likewise  have  a  deleterious  eifect  upon  the  fe- 
cundity of  women. 

The  relations  of  gonorrhoea  to  sterility  have  during  late  years  excited 
a  great  deal  of  interest  and  provoked  much  discussion.  The  extension 
of  the  gonorrhoea!  virus  from  the  vagina  to  the  uterus,  and  thence  to 
the  Fallopian  tubes,  pelvic  peritoneum,  and  ovaries,  inducing  inflam- 
mation of  a  most  rapid  and  destructive  character  in  one  or  more  of 
these  organs,  is  not  infrequent.  Such  a  result  may  take  place  long 
after  the  acute  symptoms  have  subsided  and  a  slight  gleet  alone 
remains.  These  facts  have  long  been  known  and  understood.  It 
remained,  however,  for  Dr.  Noeggerath  of  Xew  York  to  proclaim  a 
far  greater  and  more  widely-reaching  significance  to  an  attack  of  gou- 


460  STERILITY. 

orrlioea  than  had  been  accorded  it  hitherto.  His  views  concerning  the 
relations  sustained  by  the  disease,  especially  in  that  which  he  denom- 
inates its  latent  form,  were  first  published  in  1872.^  The  theory 
advanced  by  him  was  so  startling,  so  novel,  and  the  issues  involved 
in  its  acceptance  so  important,  morally  and  physically,  that  it  at  once 
challenged  the  attention  of  the  entire  medical  world.  Briefly,  his 
views  were  embodied  in  the  following  propositions : 

"  1st.  As  a  rule,  gonorrhoea,  both  in  the  male  and  female,  persists 
during  the  life  of  the  individual,  in  spite  of  apparent  cure. 
'     "  2d.  There  exists,  therefore,  a  latent  gonorrhoea  in  the  male  as  well 
as  the  female  sex. 

"  3d.  This  latent  disease,  both  in  the  male  and  female,  may  cause 
either  a  latent  or  an  acute  gonorrhoea  in  a  previously  healthy  person. 

"4th.  A  latent  gonorrhoea  manifests  itself  in  women  in  time  as 
acute,  chronic,  or  recurrent  perimetritis,  an  ovaritis,  or  as  a  catarrhal 
affection  of  the  individual  parts  of  the  mucous  membrane  of  the 
genital  tract. 

"  5th.  The  wives  of  those  men  who  at  any  period  of  their  lives  have 
had  a  gonorrhoea  remain,  as  a  rule,  sterile. 

"  6th.  Those  who  may  become  pregnant  either  abort  or  bear  only 
one  child.  In  excejDtional  cases  three  or  four  children  may  be  pro- 
duced. 

"  I  believe,"  he  says,  "  I  do  not  go  too  far  when  I  assert  that  of 
every  one  hundred  wives  who  marry  husbands  who  have  previously 
had  gonorrhoea  scarcely  ten  remain  healthy :  the  rest  suffer  from  it  or 
some  other  of  the  diseases  which  it  is  the  task  of  this  paper  to  describe. 
And  of  the  ten  that  are  spared  we  can  positively  affirm  that  in  some 
of  them,  through  some  accidental  cause,  the  hidden  mischief  will  sooner 
or  later  develop  itself." 

In  a  subsequent  paper "  Dr.  Noeggerath  reiterated  his  opinions  con- 
cerning the  influence  of  latent  gonorrhoea  on  the  fertility  of  women, 
adducing  additional  cases  and  arguments  in  their  support. 

The  extreme  views  of  Dr.  Noeggerath,  especially  those  which  imply 
the  latent  character  of  the  disease,  have  not  been  generally  accepted  by 
the  medical  profession.  While  many  cases  both  of  acute  and  chronic 
inflammatory  pelvic  disease  have  an  obscure  origin,  and  while  it  is 
freely  admitted  that  gonorrhoea  in  both  the  acute  and  chronic  stage  is 
capable  of  giving  rise  to  the  various  conditions  (perimetritis,  salpingitis, 
oophoritis,  etc.)  attributed  to  the  latent  disease,  yet  the  theory  of  life- 
long latency  seemed  so  visionary,  so  illy  sustained  by  many  of  the  cases 
cited,  and  was,  above  all,  so  discordant  with  many  well-known  facts, 
that  it  has  failed  to  enlist  very  many  adherents.     That  a  man  who  has 

^  Latent  Oonorrhcea  in  the  Female,  bv  Einil  Noeggerath,  Bonn,  1872. 
"  Trans.  Amer.  Gynecological  Society,  vol.  i.,  1876. 


jyCirACITV  FOR    LIKSTATION,  401 

a  gliH't,  liowcver  slight,  may  infect  a  woman  with  gonorHura  is  not 
tloiihlliil.  J>ut  when  all  evidences  of  the  disease  have  disapjieaicd,  and 
have  boon  absent  for  mauy  years,  lea\iiig  no  (race  liciilnd,  the  case  is 
different,  and  i'aith  must  largely   take  (he  [)laee  of  fact. 

Tin;  Ovule  may  not  Escapk  from  tmh  Ovaijy,  ou  may  not 
Reach  the  Uterine  Cavity. —  In  order  (ha(  conccpdon  may  taUe 
place  it  is  just  as  necessary  that  (he  ovide  shoidd  (ravel  outward  as 
that  spermatozoa  should  pass  inward.  It  may  be  })revented  from  doing 
this  by  thickening  of  the  follicular  walls;  imbedding  of  the  ovaries  in 
a  mass  of  inllanuuatoiy  exudation  (|)eri-o(")[)horitis) ;  closiu'c!  of  the 
Fallopian  tubes;  dilatation  of  the  l''alloj)ian  tubes  (hydrosalpinx,  pyo- 
salpinx,  hajmatosalpinx) ;  salpingitis;  ]»erisalpingitis;  peri-  and  para- 
metritis; pelvic  jxn-itonitis;  pelvic  cellulitis;  (cohesion  of  fimbrifc  to 
ovary;  closure  of  uterine  opening  of  tubes  by  metritis,  polypus,  or 
tumor;   inability  of  fimbria  to  reach  ovary. 

The  o])portunities  for  studying  pod-morion  these  more  hidden  of  the 
various  abnormal  causes  of  sterility  are  infre([uent — a  fact  which  gives 
additional  value  to  the  report  of  Wiuckel  ^  based  upon  an  examination 
of  150  autopsies  of  women  who  died  between  the  ages  of  fifteen  and 
fifty  years.  Diseases  of  the  ovaries,  tubes,  and  surrounding  structures 
of  a  character  to  make  conception  impossible  were  so  numerous,  and  so 
incapable  of  detection  during  life,  as  to  throw  much  doubt  as  to  whether 
or  to  what  extent  an  existing  sterility  may  be  caused  by  lesions  ascer- 
tainable before  death.  Atresia  of  both  tubes  was  found  in  9  cases; 
enlarged  cervical  and  corporeal  nuicous  follicles  were  found  in  22  caseS; 
in  7  of  which  there  were  also  adhesions  about  the  uterus,  tubes,  ovaries, 
and  rectum;  in  2  cases  cystic  tumors  were  found  in  both  ovaries;  and 
in  30  cases  a  single  ovary  was  cystic.  In  15  cases  conception  was 
impossible  from  abnormality  of  the  tubes. 

4.  Incapacity  for  Gestation. 

The  Ovule  may  enter  the  Uteeine  Cavity,  but  fail  to 
FIND  A  Suitable  Soil  for  its  Attachment  and  DEVEL(^p:\rENT. — 
The  raucous  membrane  which  lines  the  corpus  uteri  is  a  highly-organ- 
ized structure,  having  for  its  principal  function  the  furnishing  of  a  suit- 
able nidus  for  the  reception  and  sul)sequent  growth  of  the  ovum.  To 
do  this  it  must  be  in  a  healthy  condition.  But  iutra-uterine  disease  is  so 
frequent  that  I  have  come  to  consider  it  the  commonest  of  all  the  causes 
of  sterility.  Chronic  endometritis,  the  most  frequent  abnormal  condi- 
tion, probably  acts  in  a  threefold  manner:  1,  by  giving  rise  to  the 
characteristic  profuse  gelatinous  discharge,  and  thus  hindering  the 
ingress  of  spermatozoa;   2,  by  destroying  the  vitality  of  the  spernia- 

^  Med.-Chir.  Rundschau,  Dec,  1877. 


462  STERILITY. 

tozoa ;  3,  by  rendering  the  mucous  membrane  unfit  for  the  fixation  and 
development  of  the  ovum.  Especially  by  this  latter  method  is  it 
effective. 

Inflammatory  disease,  therefore,  while  not  necessarily  or  usually  a  bar 
to  conception,  prevents  fruitfulness  by  interfering  with  gestation.  Im- 
pregnation probably  occurs  much  more  frequently  in  these  cases  than  is 
supposed,  but  owing  to  the  defect  in  the  nesting  and  developmental 
processes  it  is  followed  by  very  early,  and  generally  unrecognized, 
abortion.  And  the  proper  ajipreciation  of  this  fact  will  furnish  the 
key  to  the  cure  of  many  otherwise  incurable  cases  of  barrenness. 

Subjective  Symptoms  of  Stebility. 

So  far,  the  causes  of  sterility  Avhich  I  have  enumerated  are  chiefly 
anatomical  in  character  and  capable  of  verification  either  before  or  after 
death.  But  inasmuch  as  disordered  function  is  always  dependent  upon 
structural  change — although  the  latter  may  be  frequently  undiscover- 
able — subjective  symptoms,  having  their  apparent  or  probable  origin  in 
the  pelvis,  should  not  be  ignored  in  any  case  under  investigation.  In 
the  table  compiled  by  Kammerer,^  out  of  408  cases  of  sterilit}^  dys- 
menorrhoea  was  noted  in  69  ;  menorrhagia  and  metrorrhagia  in  57 ; 
scanty  menstruation  in  41 ;  premature  menstruation  in  4 ;  menstruation 
never  appeared  in  2 ;  menstruation  tardy  in  8 ;  vaginismus  was  present 
in  2;  hysteria  in  16;  nervous  headache  in  3;  intercostal  neuralgia 
in  1. 

It  is  not  difficult  to  understand  how  some  of  the  foregoing  conditions 
would  be  likely  to  entail  infertility,  independently  of  their  accompany- 
ing structural  change.  Thus,  a  profuse  uterine  discharge  of  any  nature 
may  act  mechanically  by  Avashing  away  an  ovule  before  or  after  impreg- 
nation. Painful  menstruation  is  frequently — the  membranous  variety 
always — accompanied  by  sterility ;  not,  certainly,  because  of  the  pain, 
.  but  because  this  is  the  result  in  a  very  great  proportion  of  cases  of  some 
obstruction,  organic  or  functional,  to  the  free  escape  of  blood — an 
obstruction  which  we  can  readily  believe  might,  although  in  a  lessened 
degree,  interfere  with  the  ingress  of  spermatozoa. 

The  relationship  between  dysmenorrhoea  and  sterility  has  been  fre- 
quently observed,  but  whether  it  is  a  causal  one — and  if  so,  to  what 
degree  or  in  what  class  of  cases — has  not  been  settled.  Certainly,  the 
conditions  which  occasion  dysmenorrhoea  are  not  always  such  as  would 
produce  sterility.  Kehrer  found  that  a  history  of  painful  menstruation 
before  marriage  was  only  slightly  more  frequent  in  sterile  than  in  fer- 
tile women. 

The  following  table  is  based  upon  the  study  of  72  cases  of  sterility' 

^  Loc.  cit. 


SUBJECTIVE  SYMPTOMS   OF  STKllILITY. 


403 


Abnormities    of 
the  Uterus. 


Positional. 


Structural. 


occiirrin«;  in  luv  own  iir:i<'ti(T,  and  shows  the  acconipanvinji',  and  po-si- 
bly  c'tioloj^ical,    condiiions   prt-.-i-nt : 

Table  shou'iii;/   (he  AhiiDniuil  (  uiKl'dloiia  preacnl  in  7 J  t'oHOi  of  >Skr'd'dy 

ill  the  Female. 

Anteversion 3 

lietroversion      7 

I    Lateroversion 6 

I-  Desieiisus 10 

Antetle.xion 1^ 

Retri>fle.\iou 9 

Hypertrophy 1" 

Deformed  cervix 13 

Fibro-myonia 3 

Polypus 5 

Cancer    3 

Stenosis  os  externum 8 

Atresia  os  externum 1 

Stenosis  os  internum 9 

Stenosis  cervical  canal 3 

Undeveloped  uterus -i 

Small  cervix 7 

Chronic  corporeal  endometritis 17 

Chronic  cervical  endometritis 23 

f  Ovarian  tumor 3 

Chronic  pelvic  abscess 4 

]    Adherent  displacement  of  uterus 4 

j   Tubal  distension  (?) 2 

Pelvic  swellings  of  doubtful  nature 5 

Vaginitis 7 

.  Chronic  cystitis o 

f  Dysmenorrhcea 16 

Menorrhagia  and  metrorrhagia 11 

Amenorrhcea 1 

Spamenorrhoea 11 

Tardy  menstruation  (after  18  years) 3 

Premature  climacteric 2 

Dyspareunia 9 

Hysteria 7 

Irritable  bladder 12 

Impotence  (38  inquiries) 11 

Leucorrhrea 47 

r  Persistent  hymen 2 

I    Cystic  labial  tumor 1 

1   Urethral  tumor 1 

L  Vulvitis 3 

(Excessive  obesity 5 
Anaemia 3 
Secondary  syphilis 2 
Tuberculosis      3 


Extra-uterine. 


Functional  Pelvic  Abnormi- 
ties. 


Abnormities      of 
Organs. 


External 


Abnormities  of  Nutrition. 


Among  the  foregoins:  ca.ses  there  were  many  Avhicli  presented  compli- 
cations.    Thus,  a  retroverted  uterus  would  also  be  enlarged,  be  the  sulj- 


464  STERILITY. 

ject  of  enclometritis  and  its  consequent  leucorrhoea,  be  surrounded  by 
the  remains  of  pelvic  inflammation,  and  possibly  be  accompanied  by 
still  other  conditions  any  one  of  which  might  be  sufficient  to  produce 
sterility.  Indeed,  it  is  rather  unusual  to  find  a  case  of  barrenness  in 
which  only  a  single  detectable  cause  is  present ;  and  even  in  such  a  case 
there  is  always  the  possible  coexistence  of  some  one  of  the  hidden  causes 
which  have  been  enumerated.  (See  p.  457.)  In  2  of  the  cases  there  was 
a  marked  growth  of  hair  on  the  face.  In  21  cases  the  husbands  were 
questioned :  6  confessed  to  having  had  gonorrhoea ;  in  1  of  these  a 
single  testicle  had  been  inflamed,  and  in  1  both  had  been  afifected.  In 
4  cases  the  external  organs  were  examined  and  found  normal  in  all :  1 
of  these  was  aspermatic.  In  2  cases  there  was  an  admitted  history  of 
syphilis  :  1  was  cured  prior  to  marriage  ;  the  other  still  had  occasional 
mucous  patches  in  the  mouth.  In  the  72  cases  examined  there  was 
found  the  following  degrees  of  sterility  : 

Never  had  child 59 

Had  1  child 9 

Had  2  children 3 

Had  3      " 1 

Diagnosis. — Sterility  in  a  woman  is  not  a  definite  condition.  It  is 
one  which  exists  in  different  degrees;  it  may  be  absolute  or  relative, 
temporary  or  permanent,  congenital  or  acquired,  complete  or  partial. 

Sterility  is  absolute  when  dependent  upon  some  incurable  or  uncured 
condition  in  the  woman  which  would  be  efficient  under  all  circum- 
stances; relative,  when  she  is  fruitfid  with  one  mate  and  not  with 
another,  several  examples  of  this  kind  having  been  recorded.  It  is 
permanent  when  the  cause  is  not  capable  of  removal ;  temporary,  w^hen 
dependent  upon  some  curable  local  or  general  condition.  It  is  congeni- 
tal when  produced  by  some  inherent  organic  defect ;  acquired,  when  the 
deficiency  is  the  result  of  subsequent  accident  or  disease.  A  woman  is 
completely  sterile  Avhen  she  does  not  conceive  at  all ;  partially  or  com- 
paratively, when  the  degree  of  fruitfulness  is  less  than  that  of  the  aver- 
age of  women,  either  as  regards  the  total  number  of  children  produced 
or  the  length  of  time  which  elapses  between  their  births. 

Matthews  Duncan  quotes  from  Ansell's  tables,  which  he  considers 
the  most  complete  and  reliable,  to  show  that  in  6000  cases  3159  children 
— more  than  one-half — were  born  within  one  year  after  marriage;  2163 
in  the  second  year ;  421  in  the  third  ;  137  in  the  fourth ;  and  only  292 
were  born  in  all  the  subsequent  fourteen  years.  Hence  sterility  may  be 
suspected  in  a  woman  Avho  has  passed  the  first  year  of  married  life 
without  conceiving,  and  the  presumption  grows  stronger  with  each  suc- 
ceeding year,  and  after  the  fourth  the  probabilities  of  conception  are 
exceedingly  small. 


SUlUlXTlVh-  SVMI'TfJMS   OF  STIULIUTY.  K;.", 

A<'c»)r(liiii:;  to  tlu'  dcdiK'tions  of  Duiu-aii,  hascd  iijxm  tlio  tahlcs  of 
Anscll  aiul  liis  own,  the  average  interval  between  successive  eliiMren  is 
twenty  nionilis;  so  that  when  a  married  woman  do(!S  not  hear  a  child 
every  twenty  months  (hn"in<;-  the  cliildl)eai'iii;;-  period  she  oxliihits  u 
(leti"r(>e  of  ivlative  sterihty.  These  tahles  show  also  that  the  averaj^e  aj^e 
ot"  commencing;- cliildhearinii'  is  twenty-six,  and  the  mean  a<re  at  tlu;  ter- 
mination thirty-eight  years  ;  hence  the  averajic  jx'riod  of  childhearinj^ 
is  twelve  years. 

'i'he  cliildl)earin<i'  pt'riod  for  most  women  is  considerably  short ei'  than 
that  which  elapses  l)etween  the  bci^innini^  and  ocssation  of  the;  menstrnal 
fnnetion,  tlie  latter  eontinnin*^,  as  a  rule,  seven  or  eight  years  after  the 
former  has  ceased. 

Women  who  exhibit  only  a  comparative  degree  of  sterility  are  very 
numerous,  but  their  unfruitfulnoss  rarely  becomes  the  subject  of  inves- 
tigation or  treatment.  U'lieir  condition,  therefore,  as  a  class  is  of  more 
interest  to  the  })olitical  economist  than  to  the  physician.  The  women 
for  whom  medical  aid  is  likely  to  be  invoked  are  principally  those  who 
have  either  had  no  children  or  who  have  ceased  to  produce  without 
apparent  reason  after  bearing  one  or  more.  Hence,  the  diagnosis  will 
consist  not  so  much  in  determining  the  existence  of  barrenness  as  in 
ascertaining  its  cause  in  any  given  ease.  It  has  already  been  shown 
that  these  are  very  numerous,  and  not  always  apparent.  Some,  it  is 
true,  are  obvious  enough  on  the  most  superficial  examination,  while 
others  are  undiscoverable  by  the  most  careful  employment  of  all  the 
means  at  our  disposal.  And  we  should  hold  always  in  vicAV  the  import- 
ant fact  that  in  a  very  large  number  of  instances  the  causes  are  multi- 
ple, and  that  it  is  hence  necessary,  after  discovering  a  probable  one,  to 
search  for  the  existence  of  all  possible  complications.  The  methods  bv 
which  this  is  to  be  accomplished  cover  the  entire  range  of  gynecological 
diagnosis,  the  details  of  wdiich  do  not  come  properly  Avithin  the  scope 
of  this  article. 

Order  of  Invesfir/ation. — A  case  of  sterility' should  be  studied  svstem- 
atically.  While,  as  already  shown,  a  majority  of  women  conceive  dur- 
ing the  first  year  after  marriage,  and  a  very  large  number  during  the 
second,  yet  in  a  considerable  percentage  of  cases  conception  does  not 
occur  until  the  third ;  so  that  it  may  be  premature  to  conclude  that  a 
woman  is  sterile  until  after  the  end  of  three  years  of  married  life,  and 
not  even  then  unless  it  appear  that  husband  and  wife  are  in  good  gen- 
eral health  and  the  conditions  of  intercourse  favorable. 

Statements  of  the  patient  may  furnish  valuable  information  concern- 
ing the  degree  of  regularity,  character,  and  amount  of  menstrual  or 
other  discharges ;  pain,  itching,  or  other  disordei's  of  sensation ;  the 
presence  or  degree  of  sexual  desire  or  gratification.  But  these  and  all 
other  subjective  features  are  suggestive  only,  and  not  at  all  conclusive. 

Vol.  I.— 30 


466  STERILITY. 

Physieal  Examination  of  the  Female. — A  physical  examination  of 
the  woman  is  indispensable.  So  many  of  the  causes  of  sterility  are  of 
an  organic  or  mechanical  character,  and  detectable  only  by  objective 
research,  that  their  presence  or  absence  should  be  determined,  if  possi- 
ble, at  the  outset.  The  various  malformations  and  diseases  of  the  vulva 
may  be  readily  detected  by  inspection  and  touch.  If  dyspareunia  in 
any  degree  be  present,  its  cause  or  causes  should  be  carefully  sought  for. 
The  ostium  vaginae  and  vaginal  canal,  as  regards  their  size,  dilatability, 
and  degree  of  sensitiveness,  should  be  tested  by  the  careful  introduc- 
tion of  first  one  and  then  two  fingers.  The  paravaginal  structures 
should  be  interrogated  with  reference  especially  to  the  existence  of 
swellings  and  points  of  tenderness.  The  vaginal  touch  should  always 
be  supplemented  by  simultaneous  hypogastric  pressure.  In  this  man- 
ner may  be  ascertained  the  condition  of  the  uterus  as  to  size,  position, 
sensibility,  and  shape ;  also  the  condition  of  the  other  pelvic  structures, 
including  the  Fallopian  tubes  and  ovaries.  In  any  doubtful  case  the 
recto-abdoniinal  examination  should  also  be  employed,  since  by  this 
method  the  upper  and  posterior  pelvic  contents  are  brought  into  closer 
contact  with  tlie  finger.  To  ascertain  the  source  and  nature  of  abnor- 
mal discharges  an  examination  by  the  speculum  is  necessary.  By  this 
means  we  are  also  enabled  to  learn  the  size  of  the  os  uteri,  the  presence 
and  appearance  of  erosions,  ulcerations,  fistulous  openings,  or  other  con- 
ditions involving  alterations  of  color  or  character  of  surface.  By  the 
use  of  the  uterine  probe  or  sound  we  may  ascertain  the  permeability, 
size,  and  sensitiveness  of  the  orifices  and  canal  of  the  cervix. 

Such  an  examination  as  is  here  briefly  indicated,  if  carefully  con- 
ducted, should  not  fail  to  detect  any  condition  capable  of  preventing 
the  access  of  the  semen  to  the  interior  of  the  uterine  cavity,  and,  if  it 
should  prove  to  be  negative  in  results,  must  eliminate  a  very  large 
number  of  the  admitted  causes  of  sterility.     (See  p.  455  et  seq.) 

Examination  of  the  Hale. — If,  after  having  proceeded  thus  far,  no 
apparent  cause  for  the  infertility  be  found,  we  can  no  longer  assume 
that  the  fault  is  with  the  woman,  although  it  may  still  be  so,  and  the 
next  step  should  be  the  investigation  of  the  husband.  Our  inquiries 
will  have  reference  to  the  past  history  and  present  condition  concerning 
sexual  abuse,  gonorrhoea,  gleet,  urethral  stricture,  orchitis,  syphilis, 
degree  of  virility,  and  character  of  the  semen.  To  obtain  knowledge 
upon  these  points  may  require  the  exercise  of  a  good  deal  of  tact  on 
the  part  of  the  physician.  Many  men  prefer  not  to  know — or  at  least 
not  to  have  others  know — of  any  sexual  deficiency  on  their  part.  They 
are  not  averse  to  furnishing  information  concerning  their  virile  power 
when  this  is  satisfactory,  but  not  when  it  is  otherwise ;  and  in  my  own 
experience  there  has  been  on  the  part  of  most  husbands  a  very  great 
unwillingness  to  have  their  procreative  power  tested,  especially  when 


suii.ii'J'rivi'.  sYMi'foMs  or  sTi:i:ii.iiY.  407 

llic  rcsiill  (if  the  iii\csli<4;ilii)ii  scciiicd  ili  >iil)i  fill.  In  one  iiistaiicc,  in 
wliicli  I  III  re  \\:is  iiiiccrtiiiiily  :is  to  wIkhii  (Ik;  iiiriTtiiily  slioiiM  he 
ascrihid,  iIk'  IuisIkuuI  toKl  iiu-  thai  '///'/•  /  had  trailed  his  irij'r  nii.stic- 
ec.ssfu/li/  for  si.r  montha  he  would  suhmit  /limsr/f  to  utvoitif/atian. 

It'  (he  male  ori^aiis  ho  apparently  normal  in  structure  aixi  fuiiff i(»ii 
an  examination  of  the  seminal  llnid  nnder  the  micro>copc  should  ho 
mide.  A  single  di'op  is  siiHieient.  Ilie  semen  should  Ite  ohiained  :is 
soon  alter  emission  as  possihle,  and  })laee(l  under  the  slide  helore  it  has 
h'cn  exposed  to  a  low  temperature  or  other  influence  known  to  he 
inimical  to  the  vitality  of  the  sperniatozoa.  In  this  way  it  may  he 
determined  Mhether  any  spermatozoa  are  present,  and  if  so  whether 
they  he  dead  and  motionless  or  alive  and  active.  If  spermatozoa  he 
ahsent  or  without  motion,  the  man  is  sterile. 

In  order  to  ascertain  the  influence  of  the  vaginal  secretions  ui)on  the 
sjiermatozoa  the  interior  of  the  vagina  should  he  exposed  hy  a  speeuhun 
within  an  hour  or  two  after  coitus,  the  woman  in  the  mean  time  retain- 
ing the  recumhcnt  posture.  A  portion  of  the  semen  may  be  readily 
ohtained  hy  means  of  the  hypodermic  syringe  or  a  small  glass  tube, 
pipette,  or  dropping-tube.  The  cervical  mucus  may  be  obtained  in  the 
same  manner  by  previously  introducing  into  the  canal  a  pair  of  uterine 
forceps  about  half  an  inch  and  then  separating  the  blades. 

If  seminal  fluid  can  be  traced  into  the  cervical  canal,  we  may  usuallv 
assume  that  it  will  enter  the  uterine  cavity.  Nevertheless,  it  may  yet 
be  prevented  from  doing  so  by  stenosis  of  the  canal  higher  up,  by  flex- 
ions, polypi,  myo-fibromata,  etc. ;  but  the  existence  of  these  and  anv 
other  detectable  abnormities  will,  presumably,  have  already  been  ascer- 
tained. 

Hidden  Causes  of  Steriliti/. — Thus  for,  the  examination  will  have 
had  reference  to  the  conditions  of  the  spermatozoa,  and  to  those  Avhich 
may  interfere  with  their  progress  to  the  interior  of  the  uterus,  and  at 
all  stages  of  the  investigation  there  has  been  a  possibility  of  attaining 
some  degree  of  definite  result.  AVe  now  come  to  the  consideration  of 
the  various  obstacles  which  may  exist  to  the  further  progress  of  the 
spermatozoa  toward  the  ovary,  the  maturing  of  the  ovule,  its  dehis- 
cence and  transmission  to  the  uterus,  and  the  conditions  necessar}'-  for 
its  normal  implantation  and  development.  Here  all  is  doubtful ;  specu- 
lation must  take  the  place  of  observation.  The  organs  concerned  are 
beyond  our  sight  and  accurate  reach.  AVe  know,  or  believe,  that  cer- 
tain diseases,  deformities,  and  displacements  of  the  ovaries,  Fallojjian 
tubes,  and  uterus  are  caj)able  of  successfully  interfering  with  ovulation, 
conception,  and  gestation  ;  but  we  cannot  with  certainty  detect  tlieir 
presence  or  degree  during  life  unless  there  ho  enlargement,  and  not 
always  even  then.  This  seems  the  more  to  be  regretted  in  view  of  the 
fact  that  an  undeveloped  ovary,  a  contracted,  closed,  or  distended  tube. 


468  STERILITY. 

an  inflaramatoiy  exudation  or  adhesion,  an  endometritis — all  undiscov- 
erable  by  diagnostic  procedure — far  more  certainly  determine  sterility 
than  does  an  ovarian  cystoma  or  a  tumor  of  the  uterus. 

Prognosis. — The  prognosis  of  sterility  in  any  given  case  must 
depend  upon  the  nature  of  the  cause  and  its  susceptibility  of  removal. 
The  most  favorable  cases  are  those  in  which  the  barrenness  is  produced 
by  some  evident  and  removable  mechanical  impediment  to  the  access 
of  the  sperm  to  the  cavity  of  the  uterus ;  as,  for  example,  an  unbroken 
hymen,  displacements  and  flexions  of  the  uterus,  stenosis  of  the  os 
uteri  externum,  etc.  The  cases  in  which  essential  organs  of  reproduc- 
tion are  absent  or  in  which  there  exists  irremediable  impediment  to 
coitus  are  manifestly  hopeless.  Many  of  the  causes  of  dyspareunia 
are  curable,  and  in  such  cases,  provided  there  be  no  coexisting  cause 
for  the  sterility,  the  prognosis  is  favorable.  A  history  of  gonorrhcea 
in  the  husband  or  wife,  even  though  the  ordinary  symptoms  be  no 
longer  present,  is  unfavorable.  The  prognosis  is  also  bad  when  no 
cause  is  apparent,  for  this  may  consist  of  some  of  the  more  hidden 
conditions,  mechanical  or  physiological,  incapable  of  recognition  and 
unamenable  to  treatment. 

Treatment. — The  treatment  of  sterility  is  notoriously  unsatisfac- 
tory. In  order  to  be  rational  it  is  clearly  necessary  that  the  cause  or 
causes  of  the  condition  be  ascertained ;  and  it  has  been  already  shown 
how  difficult  it  is  in  many  cases  to  succeed  in  doing  this,  while  in 
others  it  is  impossible.  In  some  cases  treatment  of  any  kind  will  be 
clearly  useless;  for  example,  those  in  which  important  organs  are 
absent,  imperfectly  developed,  or  incurably  deformed,  and  those  in 
which  insurmountable  obstacles  exist  to  intercourse  or  to  the  transit 
of  semen  to  the  cavity  of  the  uterus.  Other  conditions  which  produce 
inaptitude  for  germination  (non-ovulation),  and  which  prevent  the 
transmission  of  the  ovule  to  the  uterus,  are  inaccessible  and  equally 
incurable. 

It  is  not  my  province  in  this  article  to  enter  into  a  detailed  account 
of  the  treatment  of  all  the  various  conditions  which  have  been  enume- 
rated as  causes  of  sterility.  Such  details  may  be  found  in  the  system- 
atic books  on  gynecology,  to  which  and  to  other  portions  of  this  work 
the  reader  is  referred.  Hence  what  I  may  say  concerning  the  treat- 
ment of  the  sterile  condition  will  be  merely  of  a  suggestive  or  general 
character. 

No  treatment  should  be  attempted  for  sterility  alone  which  involves 
danger  to  the  life  of  the  woman.  The  desire  for  offspring  may  be 
strong,  and  the  importance  of  an  heir  appear  under  some  circumstances 
very  great,  but  these  considerations  should  not  influence  a  surgeon  to 
imperil  a  life  by  an  operation  of  complaisance  which  must,  even  when 
successfully  done,  be  of  doubtful   efficacy.      Likewise,  no  dangerous 


SUBJECTIVi:  SYMPTOMS   OF  S'I'IHH LITY.  4G9 

operative  Ireatineiit  should  1k'  iiiKlcrlakcii  ii|i(iii  ihc  woiiiini  iiiilf--  it 
shall  previously  ajipear  beyoud  reasonable  doiiltt  dial  (lie  iludl  lies 
with  her  aud  not  with  lu'r  mate.  The  (piestiou  presents  a  diiVcrent 
aspect  when  opci'ative  or  othci'  (rcatnicnt  is  coiitcniphiicd  lor  ihe  <'iiic 
of  some  paiidul  or  dant;'erous  complication,  as  dysparcunia  or  dysmt  n- 
ori'lKca.  Here  tlu'  cond'ort  and  health  of  the  patient  are  involvf.'d,  and 
the  i-emoval  of  the  disturhinij^  clement  may  ineidentally  remove  tlie 
intertility  as  well,  the  latter  being,  however,  a  secondary  consideration. 

PiH'suino-  the  order  which  has  been  observed  in  this  article,  I  shall 
bricHv  sun'ti'est  the  treatment  suitable  ibr  die  various  causal  eniKJiiioiis 
ot"  barrenness  in  the  woman,  accoi'dinu:;  as  they  interfere  with  insem- 
ination,  imj)res;nation,  ovulation,  and  gestation. 

Tirdfiiicnt  of  Incapacity  for  Insemination. — This  class  of  causes 
includes  all  those  which  make  coitus  impossible,  diflicult,  or  j)ainrul. 
(See  }).  458  d  scq.) 

Intercourse  with  a  woman  is  always  possible  when  the  vulva  and 
vagina  are  sutheiently  pervious  to  permit  the  entrance  of  the  male 
organ,  although  the  act  may  be  difficult  or  unbearably  painful. 

W'luMi  the  sides  of  the  vulva  are  adherent,  partially  or  M'holly,  they 
juay  be  separated  by  a  knife,  scissors,  or  by  a  combination  of  cutting  and 
tearing,  the  opening  thus  made  being  maiutaiued  by  the  insertion  an<l 
retention  of  some  smooth,  hard  substance  in  the  form  of  a  cylinder  or 
plug  to  be  w^oru  in  the  vagina  until  the  raw  surfaces  have  become 
com[)letely  healed. 

More  extensive  operations  of  the  same  nature  are  indicated  when  there 
is  })artial  or  complete  closure  of  the  vagina.  If  any  portion  of  the 
vaginal  tract  be  completely  closed  and  the  uterus  and  ovaries  be 
present  aud  functionally  active,  an  operation  to  permit  exit  of  the 
retained  menstrual  fluid  may  be  demanded.  In  cases  in  Avhich  the 
occlusiou  and  retention  have  existed  for  a  long  time,  such  changes 
may  have  taken  place  in  the  internal  organs  as  to  constitute  incurable 
causes  of  infertility. 

A  double  vagina  may  be  remedied  by  removing  the  dividing  septum 
by  scissors. 

A  persistent  hymen,  if  perforate,  is  readily  removed  or  divided  Avith 
blunt-pointed  scissors,  one  blade  being  pushed  through  the  opening,  the 
incisions,  which  should  be  numerous,  being  toward  the  circumference. 
If  imperforate  it  M'ill  call  for  attention  probably  before  marriage  for  the 
symptoms  of  retention. 

Hypertrophy  of  the  clitoris  or  labia  when  so  great  as  to  be  obstructive 
to  intercourse  demands  amputation.  Vulvar  or  vaginal  tumors  should 
be  removed. 

Treatment  of  Incapacity  for  Impregnation. — The  conditions  comprised 
under  this  head  are  those  which  prevent  the  meeting  of  the  spermatozoa 


470  STERILITY. 

with  the  ovule.  (See  p.  455.)  They  are  divisible  into  two  classes,  as 
already  stated — namely,  those  which  prevent  the  semen  from  passing 
inward,  and  those  which  prevent  the  ovule  from  passing  outward. 
Some  of  these  obstructive  conditions  are  successfully  treated  with  more 
or  less  difficulty,  while  others  are  wholly  incurable — or,  rather,  the 
sterility  dependent  upon  them  is  incurable.  For  example,  a  distended 
Fallopian  tube  or  a  chronically  inflamed  ovary  may  be  removed,  but 
the  procedure  could  not,  of  course,  benefit  barrenness  dependent  upon 
disease  of  the  ablated  organ. 

When  great  disproportion  exists  between  the  male  and  female  organs 
it  may  be  proper  to  make  a  number  of  incisions  at  the  circumference  of 
the  ostium  vaginse,  and  follow  the  operation  with  the  use  of  a  large 
vaginal  plug  to  be  worn  for  two  or  three  weeks.  Otherwise,  the  con- 
dition is  irremediable. 

Nothing  can  be  done  for  a  congenitally  short  vagina;  the  condition 
persists  through  life.  Painful  urethral  caruncles  and  sensitive  mucous 
patches  on  the  vestibule  should  be  excised  and  their  bases  cauterized  by 
nitric  acid.  Fissures  of  the  ostium  vaginse  and  of  the  anus  are  com- 
monly curable  by  extensive  forcible  dilatation.  Ulcers  of  the  rectum 
should  be  treated  by  appropriate  methods,  according  to  the  extent  and 
nature  of  the  lesion.  Hemorrhoids  may  be  removed  by  ligature  or 
injection  with  dilute  carbolic  acid.  Lacerations  of  the  cervix  uteri 
should  be  closed  by  operation  whenever  they  produce  dyspareunia, 
impotency,  or  are  sufficiently  extensive  to  permit  eversiou.  Coccyo- 
dynia,  when  merely  a  neurosis,  as  it  frequently  is,  may  be  treated  as 
such,  but  when  dependent  upon  necrosis  of  the  bone,  the  latter  should 
be  removed.  Vaginismus  and  vulvar  hypersesthesia  should  be  treated 
by  removal  of  any  sensitive  remains  of  the  hymen  or  other  painful  spots, 
and  subsequent  long-continued  dilatation.  A  displaced  uterus,  if  not 
retained  in  malposition  by  adhesions,  should  be  put  in  proper  place  and 
maintained  there  by  means  of  a  suitable  pessary,  and  any  accompanying 
metritis,  endometritis,  or  subinvolution  should  be  treated  by  appropriate 
means.  Flexions  of  the  uterus  may  be  treated  by  slow  or  rapid  straight- 
ening with  bougies  having  different  degrees  of  curvature — a  method 
sometimes  temporarily  beneficial — or  by  the  use  of  intra-uterine  stems. 
If  these  means  fail  and  the  flexion  involve  only  the  cervix,  the  latter 
may  be  incised  in  such  a  way  as  to  straighten  the  canal,  and  thus  tem- 
porarily remove  the  impediment  to  egress  of  the  menstrual  discharge 
and  ingress  of  spermatozoa.  A  flexion  may  be  remedied  sometimes 
sufficiently  to  permit  conception,  but  it  is  very  likely  to  return,  some- 
times even  after  parturition. 

Many  of  the  deformities,  congenital  or  acquired,  of  the  cervix  and  os 
uteri  which  are  productive  of  sterility  are  curable  by  surgical  methods, 
while  others  are  quite  unamenable  to  all  the  resources  of  art. 


sii;.ii:crivE  sYMi"r()M><  or  stihiii.ity.  171 

All  iniporlnratc  os  iitrri  slioiild  l)c  iicatcil  hy  iiiaUiiij^  an  incision  at 
the  projuT  site  and  |)a.ssin;;  into  it  a  sound  in  <»r(|cr  to  asccrlain  tlje 
oxistoncc  and  condition  of  the  ccrvi<"il  <-anal  and  os  intcrninn.  IltliL'so 
bt'  found  sullicicntly  |)atul«»us,  it  will  only  Ix?  necessary  t<»  enlaru^c  the 
incision  ci-ucially,  and  maintain  its  patency  by  the  daily  introduction 
of  a  l»oii<^ic.  A  Ix'tter  method,  however,  consists  in  the  rciuoxal  of  a 
conical  |)ortion  one-third  of  an  in<  h  at  the  base  and  cxiendinjr  a  half 
inch  or  more  into  the  cervical  canal.  If  the  os  internum  and  e.xterniun 
be  perforate,  but  with  narrow  openin<>;s,  these  may  !)<•  (  idarucd  l)y  dila- 
tation or  incision.  If  the  method  by  dilatation  be  ch(»sen,  it  may  be 
(lone  slowly  or  ra[)idly.  Much  controversy  has  arisen  u[)on  this  subject, 
aiul  wide  ditferenccs  of  opinion  exist  as  to  which  is  the  better  metiuMl. 
If  we  accept  all  the  testimony  which  has  been  given  in  regard  to  it,  we 
must  conclude  that  all  of  the  ditt'erent  procedures  are  temporarily  suc- 
cessful ;  that  all  are  followed,  sooner  or  later,  by  a  return  of  the  stenosis ; 
that  dysmenorrhoea  has  been  relieved  in  a  large  and  sterility  in  a  smtdl 
number  of  instances;  that  all  are  likely  in  a  small  percentage  of  cases 
to  be  followed  by  endometritis,  pelvic  cellulitis,  or  peritonitis.  My  own 
preference  is  for  rapid  dilatation  under  anaesthesia,  and  the  maintenance 
of  the  patency  thus  obtained  by  the  introduction  of  a  hard-rubber  bou- 
gie at  intervals  of  three  or  four  days  in  the  beginning,  and  then  of 
from  one  to  four  weeks.  The  instrument  should  be  carried  into,  and 
not  beyond,  the  internal  os  one  or  two  days  before  an  expected  men- 
strual period. 

Hypertrophic  elongation  of  the  cervix  should  be  treated  by  amputa- 
tion of  the  redundant  tissue  with  a  knife  or  galvanic  cautery.  "When 
one  of  the  uterine  lips  projects  beyond  the  other,  overlapping  and 
partly  closing  the  os  uteri,  the  projecting  portion  should  be  removed 
sufficiently  to  restore  the  symmetry  of  the  parts. 

Fibro-myomata  of  the  uterus  should  be  dealt  with  quite  independ- 
ently of  their  influence  upon  fecundity.  If  the  symptoms  produced 
by  their  presence  should  be  so  grave  as  to  impair  health,  they  should 
become  the  object  of  either  palliative  or  radical  treatment,  the  details 
of  which  will  depend  upon  the  size  and  position  of  the  tumor  and  the 
age  and  general  condition  of  the  patient.  The  methods  of  treatment 
most  relied  upon  are  the  administration  of  ergot,  enucleation,  removal 
of  the  ovaries,  and  hysterectomy.  Manifestly,  these  methods  wotdd 
some  of  them  only  ensure  sterility. 

Uterine  polypi,  when  productive  of  hemorrhage,  pain,  or  catarrh, 
should  be  removed  by  torsion,  the  ecraseur,  scissors,  or  gal  vain  »- 
cautery. 

The  dense,  viscid,  mucous  plug  which  is  so  constantly  present  as  a 
result  of  chronic  cervical  endometritis  may  be  removed  temporarily  by 
means  of  small  pieces  of  sponge  the  size  of  a  pea  held  in  the  blades  of 


472  STERILITY. 

a  forceps.  It  is  frequently  a  tedious  process,  however.  The  menstrual 
discharge  usually  washes  it  away,  so  that  for  two  or  three  days  after  a 
period  very  little  of  it  can  be  seen.  In  all  cases  an  effort  should  be 
made  to  cure  the  intracervical  disease  which  causes  it — commonly  a 
difficult  matter.  An  essential  requisite  iii  the  treatment  of  this  obsti- 
nate disease  is  thorough  dilatation  of  the  canal  in  order  that  the  mucus 
should  be  permitted  to  escape  so  soon  as  formed,  and  to  enable  any 
therapeutic  application  to  come  fairly  in  contact  with  the  secreting  sur- 
faces. The  opening  should  be  sufficiently  large  to  permit  the  introduc- 
tion of  a  No.  16  bougie  prior  to  each  application.  Much  of  the  fail- 
ure to  treat  this  disease  successfully  is  to  be  attributed  to  the  omission 
of  this  preliminary  measure :  with  it,  I  have  usually  succeeded  in 
removing  cervical  inflammation  of  very  long  standing,  and  am  obliged 
only  rarely  to  resort  to  the  ablation  of  the  glandular  structure,  although 
this  must  sometimes  be  done. 

For  excessive  acidity  of  the  vaginal  mucus  an  alkaline  treatment 
should  be  adopted,  including  alkaline  drinks,  baths,  and  vaginal  injec- 
tions. Solutions  of  bicarbonate  of  soda,  borax,  Vichy  water  (Pajot) 
are  suitable  for  this  purpose.  Byasson  recommends  as  an  injection 
the  following:  Water,  1000  grammes,  the  white  of  one  egg,  and  90 
graonnes  of  phosphate  of  soda.  In  this  solution  he  was  able  to  keep 
spermatozoa  alive  for  twelve  days.  It  is  probable  that  the  occasional 
successful  results  which  have  attended  courses  of  treatment  at  alkaline 
springs  and  baths  have  been  in  this  class  of  cases. 

Treatment  of  Incapacity  for  Ovulation. — Strictly  speaking,  the  term 
"  ovulation  "  includes  only  the  processes  concerned  in  the  germination, 
maturation,  and  dehiscence  of  the  ovule.  But  for  my  present  purpose 
I  desire  to  include  also  its  transmission  from  the  ovary  to  the  cavity  of 
the  uterus.  In  this  enlarged  sense  the  conditions  which  may  interfere 
with  the  series  of  processes  necessary  for  conception  are  very  numerous. 
(See  p.  461.)  So  far  as  these  pathological  states  may  affect  injuriously 
the  health  of  the  subject,  they  may  interest  the  surgeon,  for  many  of 
them  are  curable  by  surgical  methods,  but  inasmuch  as  the  cure  involves 
in  many  cases  the  removal  of  the  ovaries  and  Fallopian  tubes,  the  ster- 
ility is  made  absolute.  It  is  true  that  recovery  may  take  place  after 
repeated  attacks  of  pelvic  inflammation,  and  that  lapse  of  time  may, 
with  suitable  persistent  treatment,  bring  resolution  and  absorption  of 
inflammatory  exudations ;  but  after  the  pelvic  organs  have  become  sol- 
idly matted  together  with  adhesions  such  recovery  must  be  rare,  if, 
indeed,  it  ever  occurs.  Any  treatment  of  the  inflammatory  affections  of 
the  pelvic  structures,  so  far  as  these  relate  to  the  sterile  condition,  must 
be  made  in  the  earlier  stages  of  the  disease  in  order  to  be  effective. 

Treatment  of  Incapacity  for  Gestation. — This  depends  chiefly  upon 
the  presence  of  a  diseased  condition  of  the  endometrium  which  pre- 


SUIUITTIVK  SYMPTOMS   OF  STKIUIJTY.  473 

vents  j)r()(liicti\'('iicss   l)\-  intri-fci-in^ w  ilh    (ixalion   and  (li'vclnpinciit  of 
tlic   nviliii. 

\\  lu'ii  we  foiisidcr  Imw  iiiaii\  ol  ilic  piMx^csseH  (;<)iici'nii(l  in  L''<'ii('ra- 
tioii  ;iro  wliollv  nKH'liaiiical,  it  docs  not  soeiii  sui'prisinj;-  that  in  <a-(-  of 
sterility  j)rt'S('ntiii<2;  some  apparent  ol)stacle  of"  a  |)liysi(al  diaiactt  r  lliis 
should  l»f  promptly  accepted  as  th(!  elli(!ieiit  cause,  an<l  that  ni(!chaniciil 
metliods  should  he  resorted  to  lor  relief".  And  it  is  uiKpiestionahle  that 
verv  many  oi'  the  conditions  which  have  heen  mentioned  as  causes  of 
infertility  can  he  o\  iieonie  only  by  sui*j2;ical  mean.--,  li  is  c(|ually  true 
that  the  mere  I'cmoval  of  such  ohsf laiction  may  he,  and  frecjuentlv  is, 
suilicieiU.  IWil  there  are  many  cases  in  which  soniethinj^  more  is 
needed — cases  in  which  operative  and  medianical  methods  do  not 
meet  all  the  requirements.  For  exann)le,  a  pronounced  flexion  of 
the  uterus  is  a  frequent  cause  of  sterility;  and  clinical  exj)ericnce  has 
seemed  to  demonstrate  that  the  efficient  removal  of  the  distortion  and 
tlie  enlargement  of  the  abnormally  small  cervical  ciinal  have  been 
sometimes  followed  by  conception.  Far  oftener,  however,  these  means, 
while  promptly  relieving  the  accompanying  dysmenorrhoca,  have  failed 
to  remove  the  sterility — failed,  doubtless,  for  the  reason  that  they  did 
not  remove  some  other  condition  than  the  mere  narroAving  of  the  cer- 
vical canal,  and  which  was  the  potent  factor  in  production  of  the  bar- 
renness. And  even  in  those  cases  in  which  conception  has  followed 
the  use  of  the  surgical  means  for  enlarging  a  narrow  cervical  canal  the 
fact  does  not  at  all  prove  that  the  result  was  a  consequence  of  the  mere 
enlargement  of  the  passage-way;  for,  wdiether  the  operation  be  done  by 
dilating  or  cutting  instruments,  something  more  is  effected  than  the 
mere  stretching  and  cutting.  Indeed,  these  procedures  make,  in  addi- 
tion, a  very  profound  impression  not  only  upon  other  portions  of  the 
uterus  than  those  directly  attacked,  but  one  which  extends  also  to 
neighboring  parts.  And  I  do  not  doubt  that  long-standing  conges- 
tions and  inflammations  wdiich  have  prevented  the  uterus  from  j)rop- 
erly  receiving  and  nourishing  the  ovum  have  sometimes  been  thus 
removed.  Further,  I  believe  that  it  is  because  the  diseased  conditions 
mentioned  or  similar  ones  are  not  always  removed  by  the  operations  re- 
ferred to  that  sterility  is  not  more  frequently  cured  by  their  employment. 
The  same  may  be  said  of  displacements  of  the  uterus,  which  are 
thought  by  many  to  be  the  most  frequent  of  all  the  mechanical  causes 
of  sterility.  In  a  paper  read  before  the  American  Gynecological  Soci- 
ety* I  made  the  following  statement  in  regard  to  the  relations  existing 
between  sterility  and  uterine  displacements:  "Of  these,  retrovei*sion 
and  anteversion  form  the  great  bulk,  prolajisus  being  com]xirativelv 
infrequent,  and  even  when  present,  not  likely,  per  se,  to  prevent  con- 
ception.    Even  the  versions  of  the  uterus  are  not  necessarily  produc- 

*  Ih-ansaclions,  1879. 


474  STERILITY. 

tive  of  infertility.  They  may  constitute  a  difficulty  in  the  way  of 
impregnation,  but  nothing  more ;  and  they  only  do  this  when  the  os 
uteri  is  pressed  against  the  vaginal  wall  or  carried  far  from  its  normal 
position.  That  these  malpositions  are,  however,  sometimes  the  only 
causal  elements  of  the  sterility  is  shown  clinically  by  the  success  which 
occasionally  follows  the  replacement  of  the  organ  and  its  retention  in 
proper  position  by  means  of  pessaries.  But  here  too,  just  as  in  the  case 
of  flexions,  these  mechanical  devices  are  only  exceptionally  successful. 
In  the  great  majority  of  cases  they  fail.  AVhy  ?  Because  nine-tenths 
perhaps  of  all  chronic  uterine  displacements  are  complicated  ^vith 
chronic  uterine  disease,  which  the  mere  replacement  of  the  organ  is 
inadequate  to  remove.  Practically,  it  does  not  matter,  so  far  as  the 
therapeutics  of  these  coexistent  conditions  are  concerned,  whether  the 
inflammation  or  hypertrophy  (or  %vhatever  the  disease  may  be)  or  the 
malposition  has  appeared  first — which  is  the  cause  and  which  the  effect. 
We  find  them  together,  and  both  must  be  cured.  Usually,  they  must 
be  cured  simultaneously  if  at  all;  for  curing  one  does  not,  unless  excep- 
tionally, cure  the  other.  And  just  here  we  have,  as  I  believe,  the  fun- 
damental fact  which  explains  why  mechanical  treatment  alone  so  often 
fails  to  remedy  the  sterile  condition.  A  displacement  or  a  flexion  is 
rectified,  perhaps,  but  an  endometritis  which  coexists,  and  which  is  the 
potent  factor  of  causation,  is  not  removed,  and  the  sterility  remains. 
Not  only  this :  from  the  persistence  of  the  inflammation  the  displace- 
ment or  deformity  itself  is  likely  to  return.  Hence,  w4iile  we  cannot 
discard  the  pessary,  and  while  by  its  use  great  amelioration  of  the 
patient's  symptoms  may  be  effected,  and  while,  still  further,  the  mere 
replacement  of  the  uterus  may  sometimes  be  sufficient  to  restore  the 
organ  to  a  healthy  state,  we  cannot  rely  upon  this  latter  result.  So, 
when  sterility  complicates  displacement  we  must  expect  to  find  disease 
also,  and  this  latter,  as  well  as  the  malposition,  must  be  removed  if  we 
would  cure  the  barren  condition." 

In  cases  of  sterility  attended  by  inflammatory  disease  of  the  pelvic 
organs  too  much  stress  cannot  be  put  upon  the  importance  of  sexual 
repose.  This  can  frequently  only  be  obtained  by  separation  of  hus- 
band and  wife. 

It  has  been  generally  thought  that  conception  is  much  more  likely  to 
occur  within  a  few  days  subsequent  to  a  menstrual  period.  This  belief 
was  based  upon  the  theory  which  regarded  menstruation  only  as  depend- 
ent upon,  and  an  epii)henomenon  of,  ovulation — a  theory  so  inconsist- 
ent with  many  now  admitted  facts  as  to  be  no  longer  held  by  some,  and 
very  loosely  by  others.  Fecundation  may  result  from  a  coitus  had  at 
any  time  between  two  menstrual  epochs,  the  essential  requisite  being  the 
junction  of  the  ovule  and  spermatozoa.  Nevertheless,  it  is  still  true 
that  the  most   favorable  period   for  the   occurrence  of  conception    is 


AJrnilrJAL    IMl'lLlKiSATlOS.  17.'* 

within  the  \\\>>{  ci^lit  or  ten  days  after  tlio  cessation  of  a  iiiciistnial 
How,  ht'caiist'  the  iiicroascd  coii^cstioii  (»t'  all  tin-  |M'lvic  orj;aiis  (liiriii;^; 
the  talaiiH'iiial  (luxinii  occasionally  dclcniiiiio  the  more  hasly  nij)tiire 
ul"  a   iiiaiure   lollicle. 


Artificial  Impregnation. 

1m  certain  cases  of  sterility  it  may  he  i»ro[)er  t<j  attempt  artificial 
impregnation.  This  consists  in  the  mechanical  intnxluction  ui'  sper- 
matic Hnid  into  the  uterine  ("avity.  The  eases  which  are  es|x*cially 
aila[)ted  t<»  tliis  metluxl  of  treatment  are  those  in  which  there  is  some 
obstacle  to  the  passage  of  the  si)ermatoza  from  the  vagina  to  the  inte- 
rior of  the  ntmuis,  as  occurs  in  Hexions  of  the  neeU  on  the  b<xly  of  the 
oruan  and  stenosis  of  the  cervical  canal. 

Prior  to  resorting  to  this  method  it  should  he  certainly  known  that  the 
hushand  is  fecinid,  as  indicated  by  a  u<^»rmal  condition  of  the  semen; 
that  the  menstrual  function  is  properly  performed  ;  tiiat  the  pelvic  and 
genital  organs  of  the  female  are  normal ;  that  all  other  rational  meth<M:ls 
of  treatment  have  failed.  In  every  case  the  consent  of  both  husband 
and  wife  should  be  obtained. 

The  attempt  having  been  decided  upon,  coitus  is  practised  in  the 
ordinary  manner.  Subsequently,  within  one  or  two  hours,  the  woman 
having  in  the  mean  time  maintained  the  recumbent  posture,  a  small 
quantitv'  of  the  semen  in  the  vagina  is  drawn  into  a  properly-con- 
structed syringe  which  has  been  previously  warmed  to  the  temperature 
of  the  body.  The  tip  of  the  instrument  is  then  carried  through  the 
cervical  canal  to  a  point  just  beyond  the  os  internum,  when  a  single 
drop  is  forced  forward  by  a  partial  turn  of  the  piston.  The  tul)e  is 
held  quietly  in  the  cervix  for  a  few  seconds,  and  then  carefully  with- 
dj'awn.  The  woman  should  lie  in  bed  several  hours  immediately  fol- 
lowing the  operation.  Girault  ^  prefers  to  the  syringe  a  hollow  sound 
for  the  introduction  of  the  semen.  The  instrument,  properly  charged, 
is  placed  within  the  neck  of  the  uterus,  and  the  fluid  is  discharged  by 
blowing  through  the  tube  with  the  mouth  of  the  operator. 

Tiie  degree  of  success  which  has  attended  the  meth(xl  of  artificial 
impregnation  is  not  known.  During  the  year  1866  the  late  Dr.  Mar- 
ion Sims  made  55  experiments  on  6  different  women.  Many  of  the 
operations  were  imperfectly  done  or  performed  under  unfavorable  cir- 
cumstances. In  a  single  instance  conception  occurre<l,  but  even  this 
was  inconclusive,  since  the  exj>eriment  was  ])recede<l  and  followed  bv 
ordinary  cohabitation.  Girault^  has  had  eight  successes,  0!ie  a  twin 
pregnancy;  the  number  of  experiments  not  given.     De  Sinety^  says: 

'  Etude  mr  la  Generation  nrtificielle  dansPE-ip^ce  humaine,  Paris,  1869. 
*  Loc.  ci(.  '  Manuel  de  Gi/necologie,  1879. 


476  STERILITY. 

"  The  successes  obtained  after  eight  or  ten  futile  attempts  are  an 
encouragement  for  the  repetition  of  this  manoeuvre  a  certain  number 
of  times."  Richard  ^  states  that  Gigon,  Lessueur,  Delaporte,  and  other 
French  physicians  have  also  been  successful  in  artificial  fecundation,  but 
does  not  give  details. 

Artificial  impregnation  has  never  become  popular  with  the  medical 
profession,  notwithstanding  the  great  scientific  interest  which  attaches 
to  the  subject.  Many  have  condemned  the  practice  without,  it  seems 
to  me,  any  very  good  reason.  It  aims  to  accomplish  by  comparatively 
harmless  means  an  end  which  all  gynecologists  are  willing  to  attain  by 
more  dangerous  methods,  for  surely  no  one  can  claim  for  the  various 
remedies  in  vogue  for  overcoming  flexions  and  stenosis  of  the  cervix 
uteri  a  degree  of  safety  at  all  comparable  with  that  used  in  artificial 
impregnation.  Objections  which  have  been  sometimes  urged  on  merely 
ethical  grounds  may  very  properly  be  left  for  the  disposal  of  the  parties 
chiefly  interested — namely,  the  husband  and  wife. 

Eustache  ^  says :  "  This  last  intervention — ultima  ratio — is  not  con- 
demned by  either  morality  or  religion;  it  is  justified  by  the  essentially 
legitimate  and  essentially  moral  desire  to  have  children,  and  also  by  a 
certain  number  of  incontestable  successes." 

'  Histoire  de  la  Generation,  p.  255. 

^  Manuel  pratique  des  Maladies  des  Femmes,  1881,  p.  732. 


DISEASES  OF  THE  VULVA 

By  MATTIIKW  D.  MANN,  A.M.,  M.  D., 

liUFFALO,    N.  Y. 


Malformations  of  the  Vulva. 

As  the  congenital  nialf'orniations  of  the  vulva  have  been  already 
fully  described/  it  is  only  necessary  to  say  here  a  few  words  concern- 
ing their  treatment,  so  far  as  that  may  be  required. 

Hypospadias  and  Epispadias  are  virtually  incurable  defects,  but  the 
discomfort  and  annoyance  can  sometimes  be  materially  diminished  by 
carefully  devised  plastic  operations.  AVhere  the  anterior  wall  of  the 
urethra  is  wanting,  even  when  the  defect  extends  entirely  through  the 
mons  Veneris,  flaps  can  be  obtained  from  the  sides  and  the  parts  brought 
together,  so  as  materially  to  better  the  patient's  condition,  and  even 
give  retention  of  urine.  Schroeder^  reports  two  successes  where  these 
conditions  existed.  In  hypospadias  the  chances  of  success  are  much 
less,  and  the  patient  is  reduced  to  the  necessity  of  wearing  a  urinal. 
Several  have  been  devised  for  these  cases  expressly. 

In  hcnnapJvodism  no  special  treatment  or  operation  is  indicated. 

The  clitoris,  if  greatly  enlarged,  and  the  source  of  discomfort,  may 
with  safety  be  amputated.  INIason^  successfully  amputated  with  the 
^craseur  a  clitoris  four  inches  long. 

The  labia  minora  are  sometimes  very  large,  but  they  seldom  cause 
anv  inconvenience.  In  those  cases  in  which  there  is  a  supersensitive  ct)n- 
dition  of  these  organs,  Carrard^  has  '' verv  recentlv  been  able  to  show 
that  the  cause  is  an  increase  of  their  nerve-fibres  in  the  form  of  INIeiss- 
ner's  tactile  bodies,  also  in  the  form  of  club-shaped  terminations  and 
peculiar  tactile  bodies  having  an  aggregation  of  adenoid  tissue."  If 
such  conditions  exist,  they  are  of  course  incurable,  and  can  only  be 
relieved  by  the  total  excision  of  the  affected  organs.  In  other  cases 
there  is  simply  chafing  from  clothing,  or,  in  very  stout  women,  from 

^  See  article  on  Malformations  of  the  Female  Genitals.  ]i.  2G4. 

2  Lehrbuch  d.  Gyn.,  v.  Aufl.  •''  New  York  Mcdiml  Review,  May  1,  1868. 

*  Quoted  by  Winckel  from  ZeiUchriJ't  /.  Oeburish.,  x.  62. 

477 


478  DISEASES  OF  THE   VULVA. 

contact  with  surrounding  parts.  The  result  is  more  or  less  burning 
and  itching,  which  produce  a  great  deal  of  discomfort,  and  may  inter- 
fere with  locomotion  or  the  sexual  act. 

These  symptoms  may  be  relieved  by  hot  baths,  astringent  lotions, 
ointments,  or  dry  powders,  as  talc,  bismuth,  and  boric  acid.  If,  how- 
ever, the  symptoms  j)ersistently  recur,  removal  of  the  parts  may  be 
indicated.  The  operation  is  a  simple  one,  and  can  be  done  with  knife 
or  scissors,  and  the  edges  brought  together  with  fine  continuous  suture. 
If  hemorrhage  is  feared,  the  cautery-knife  may  be  used. 

Masturbation,  it  has  been  asserted,  sometimes  results  in  hyper- 
trophy of  the  nymphffi,  and  even  of  the  clitoris.  To  this  many 
objections,  based  on  accurate  observations,  have  been  made.  The  worst 
case  of  masturbation  I  ever  saw,  presented  abnormally  small  clitoris 
and  nymphse,  and  I  have  several  times  seen  Avell-marked  hypertrophy 
where  the  most  positive  assurances  made  the  existence  of  this  habit  out 
of  the  question.  On  the  other  hand,  there  is  good  ground  for  thinking 
that  unilateral  hypertrophy  of  the  nymphse  may  result  from  long  con- 
tinuance of  the  habit.  A  number  of  cases  bearing  on  this  point  have 
been  reported ;  ^  and  while  it  can  by  no  means  be  considered  as  patho- 
gnomonic, still  its  presence  must  give  rise  to  a  very  strong  suspicion. 
It  is  noted  that  in  the  case  of  right-handed  women  the  right  labium 
is  enlarged,  and  in  the  left-handed  the  reverse  occurs. 

As  additional  jDoints  in  the  diagnosis  of  masturbation.  Dr.  Routh  and 
Dr.  Hey  wood  mention^  that  they  have  observed  that  in  Avomen  guilty 
of  this  practice  the  pudendal  hair  is  straight.  Dr.  Heywood  has  also 
noticed  that  in  many  cases  the  nymj^hse  were  not  only  lengthened,  but 
granular  on  their  external  aspect,  and  had  flattened  follicles  filled  Avith 
sebaceous  matter.  This  condition  of  the  labia  may  perhaps  be  a  cause 
rather  than  a  result  of  masturbation,  the  continual  local  irritation 
directing  the  Avoman's  attention  to  the  parts.  I  have  seen  it  exist 
without  any  signs  of  the  practice. 

The  operation  of  removing  the  clitoris  and  nymphse  for  the  cure  of 
masturbation  and  nymphomania  Avas  at  one  time  much  practised  ;  but 
after  a  very  bitter  controversy,  Avhich  makes  one  of  the  most  unhappy 
episodes  in  gynecological  history,  it  Avas  condemned,  and  has  been 
almost  entirely  giA^en  up. 

Atresia  may  be  either  congenital,  or  acquired  during  infancy  or  child- 
hood. It  is  very  rarely  met  Avith,  In  the  acquired  form  agglutination 
of  the  labia  takes  place  as  the  result  of  inflammation  or  ulceration.  In 
either  case,  Avhen  discovered,  the  adherent  surfaces  should  be  torn  or 
dissected  apart,  and  the  raw  surfaces  kept  from  again  uniting  by 
pledgets  of  lints  placed  between  them. 

■^  British  Gynecologiaal  Journal,  Feb.,  1887,  p.  503. 
^  Brit.  Gyn.  Journ.,  he.  cit.,  p.  505. 


is.n'i:fi:s  axd  n'oiwDs  of  the  vulva. 


479 


Injuries  and  Wounds  of  the  Vulva. 

Iiijiirics  (•('  the  \iil\;i  may  l)c  (Ii\iili'il  iiiti>  three  classes,  aoconlinjr  to 
tlu'ir  cause:  tlicv  may  be  in-otliircd  hy  accidental  external  violence, 
(liUMiiir  coitus,  and  dnrint:'  lal)or. 

W'oiNDs  I )r K  ro  Accidental  External  Violenxe. — Tlie  gen- 
ital or<i;ans  are  so  well  protected  by  their  loeati(jn  that  accidental 
woinuls  are  necessarily  rare.  The  most  common  accident  is  a  I'all 
on  some  sharp  body,  which  may  thus  bruise,  cut,  or  penetrate  the 
]>art,  AVounds  ot"  this  descrijition  are  also  met  with  amontr  tlie  lower 
classes  from  kicks  with  heavy  boots.  In  this  case  the  vulva  maybe 
onlv  bruised  ;  or,  should  the  tissues  be  caught  between  the  boot  and  the 

Fig.  176. 


Veins  of  the  Vulva  (Kobelt) :  a,  bulb  of  the  vagina ;  /(,  dorsal  vein  of  the  clitoris ;  e,  inter- 
mediary plexus ;  g,  vein  of  commuuication  with  the  obturator  vein ;  I,  obturator  vein. 

pribes,  a  wound,  almost  as  clean-cut  as  though  made  by  a  knife,  may  be 
made.  The  labia  majora  are  the  parts  mo-st  generally  injured  ;  but  the 
deeper  parts  may  also  be  affected,  and,  although  not  cut  through  at 
once,  may  slough  subsequently.  In  this  way  the  nympha?  and  clitoris 
mav  be  injured,  and  even  a  portion  of  the  urethra  lost.  The  nature  of 
the  wound  due  to  a  fall  must  depend  entirely  on  the  object  inflicting 
the  injury.  If  the  person  fall,  for  example,  on  the  sharp  back  of  a 
chair  or  the  edge  of  a  box,  a  deep  cut  may  be  made.  Should  the 
object  be  smaller,  it  may  enter  the  vagina  and  cut  or  penetrate  its 
walls. 


480  DISEASES  OF  THE   VULVA. 

The  symptoms  are  pain  and  hemorrhage  if  the  skin  has  been  broken, 
soon  followed  by  swelling,  and  later  in  some  instances  by  sloughing.  In 
case  the  skin  is  not  broken,  but  the  deeper  and  softer  tissues  ruptured, 
a  rapid  eifusion  of  blood  may  take  place  into  the  tissues,  forming  a 
large  tumor  known  as  a  pudendal  hsematoma. 

If  the  deeper  structures,  as  well  as  the  skin,  are  opened,  a  very  pro- 
fuse hemorrhage  will  follow.  This  will  be  particularly  severe  in  case  of 
the  rupture  of  the  large  veins  (Fig.  176)  in  the  neighborhood  of  the  clito- 
ris and  nymphse.  These  veins,  being  valveless  and  very  large,  allow  of  a 
rapid  loss  of  blood.  If  the  vagina  be  penetrated,  any  of  the  surround- 
ing organs  may  be  wounded  and  inflammation  follow. 

Injuries  from  Coitus. — It  is  certainly  a  very  strange  circumstance 
that  sexual  intercourse  is  sometimes  attended  with  severe,  and  even  dan- 
gerous, laceration  not  only  of  the  hymen,  but  of  the  vulva  and  vagina  as 
well.  The  possibility  of  this  has  been  doubted  by  some  high  authorities, 
but  the  evidence  seems  too  strong  to  be  denied.  Sir  Spencer  AVells, 
Munde,  Chadwick,  Schroeder,  and  others^  have  reported  cases  where 
this  accident  has  undoubtedly  happened.  In  some  instances  the  extent 
of  the  injuries  makes  it  seem  almost  impossible  that  the  finger  or  some 
other  instrument  was  not  used.  Eents  have  been  recorded  of  the  hy- 
men and  vestibule ;  of  the  fossa  navicularis,  extending  into  the  rectum, 
making  a  vulvo-rectal  fistula ;  of  the  anterior  vaginal  wall,  making 
a  vesico-vaginal  fistula;  and  of  the  posterior  wall,  making  a  recto- 
vaginal fistula. 

The  causes  noted  have  been  extreme  violence  in  the  sexual  act, 
excessive  disproportion  between  the  male  and  female  organs,  narrow- 
ness of  the  vagina,  as  in  very  young  and  very  old  women,  and  unnat- 
ural positions  in  coitus. 

The  symptoms  have  been  extreme  pain  during  coitus,  and  hemor- 
rhage, sometimes  of  an  alarming  kind.  The  flow  is  esjoecially  free  if 
the  bulb  of  the  vagina  is  torn.  Permanent  fistulas  have  been  observed 
to  follow  these  lacerations  (Price,  Wells,  and  others). 

Injuries  during  Parturition. — The  discussion  of  these  injuries 
belongs  more  properly  to  writers  on  obstetrics.  Their  prevention  can 
only  be  achieved  by  a  proper  management  of  the  second  stage  of  labor, 
and  even  with  the  greatest  exercise  of  skill  is  not  always  possible. 
Their  immediate  treatment  seldom  falls  to  the  gynecologist,  but  the 
secondary  operations  make  up  a  considerable  share  of  his  surgical 
work.     This  subject  will  be  treated  of  in  a  separate  article. 

Treatment — The  treatment  in  all  the  above  cases,  except  those  due 

to  labor,  must  vary  with  the  severity  and  nature  of  the  injury.     If  it 

be  a  simple  bruise  of  the  labia,  cold  applications  and  rest  will  be  all 

that  is  required.      If  there  be  deep  cuts,  they  should  be  carefully 

^  Am.  Journ.  Obstetrics,  vol.  xix.  p.  832. 


i.\.j{i:ii:s  A.\n  woiwds  of  riii-:  vilva.  4.si 

(•l('aii>f<l  with  ail  aiili>i'|)tif  sdliitioii,  all  torti  liit-  <tl  ti.->ii('  tiiiiiiin-<l 
otV,  and  the  (hIj^os,  as  well  it<  the  (Iccjxr  pail.*,  I)i(iii};lit  to^ctlicr  with 
sutures  if  |Htssil)li'.  I)raiiia<i:('-tulH's  will  .seldom  he  rc(|iiin'f|.  If  \iu- 
leiit  lu'inorrhatic  he  iircsciil,  dccj)  sMtiiivs  arc  f^ciicrally  the  hcst  method 
of  control  lint;-  it,  all  lar<ic  arteries  havinj;  been  fii>t  earefiilly  twisted, 
or  tied  with  eatirnt.  .\>  the  heiii(irrha<ic  is,  as  a  nde,  mostly  venous, 
if  the  sutures  do  iKtt  control  it,  linn  pressure  hy  a  comiM-e-^  and  a 
T  l)anda<i:e  will   usually  suffice, 

\\'hen  we  have  to  deal  with  a  decj)  |)enetratinL^  wound  olthe  vatriiKi, 
il'  the  licmorrhage  be  severe,  a  carel'ul  examination  of  the  wound  throuj^h 
a  spociduin  should  first  be  made,  sutures  applied  if  necessary,  or  the 
va*>:ina  may  be  securely  tamponetl.  The  tain])()n  can  be  moistened  with 
alum-water  and  freely  sprinkled  with  iodoform,  in  which  case  it  may 
be  safely  left  in  place  for  four  or  five  days,  without  fear  of  decomposition 
and  conse(|uent  sepsis.  If  the  perineum  be  torn,  it  may  be  closed  by 
sutures  at  once,  as  in  the  ordinary  secondary  operation.  If  the  injury 
is  confined  to  the  hymen  or  to  more  superficial  parts,  a  tampon  may  be 
api)lied  to  fill  the  vauina,  before  making  compression  with  a  pad  and  a 
T  bandage. 

Where  operations  for  the  closure  of  wounds  of  the  vulva  are  under- 
taken, even  in  very  unpromising  cases,  careful  antisepsis,  such  as  wash- 
ing Avith  carbolic  or  sublimate  solutions,  Avith  the  free  use  of  iodoform, 
aided  by  the  naturally  high  vascularity  of  the  parts,  Avill  generally 
secure  primary  union. 

In  the  case  of  young  children,  ail  defects  due  to  injuries,  old  or 
recent,  should,  if  possible,  be  repaired  before  puberty,  as  it  can  scarcely 
be  doubted  that  the  subsequent  regular  development  of  the  parts  will 
go  on  more  naturally. 

As  regards  the  injuries  due  to  childbearing,  professional  opinion  is 
pretty  well  agreed,  that  the  primary  operation  is,  in  any  but  the  most 
trivial  cases,  the  proper  treatment.  In  the  lesser  degrees  of  laceration 
the  writer  has  a  number  of  times  seen  most  excellent  results  from  the 
use  of  the  serres-fincs.^ 

AYliere  the  laceration  extends  through  the  sphincter  ani  and  up  the 
recto-vaginal  septum,  the  advisability  of  the  immediate  operation  is  not 
so  generally  conceded.  The  writer  would  give  it  as  his  opinion,  after 
some  very  fortunate  results,  that  an  operation  is  not  oidy  possible,  but 
is  strongly  indicated.  The  use  of  antiseptics  makes  danger  from  im- 
prisf>ned  fetid  lochia  a  purely  preventable  danger,  and  one  which  should 
not  contraindicate  the  operation.  If  union  occurs,  the  patient  is  saved 
from  a  great  deal  of  suffering  ;  and  if  it  fails,  the  success  of  a  secondary 
operation  is  in  no  way  interfered  with.  Alloway's  method"  has  in  my 
hands  proved  satisfactory,  not  only  in  the  lesser  degrees  of  laceration, 

'  Am.  Joum.  Obstet.,  Nov.,  1874.  ^Am.  Journ.  Obstet.,  vol.  xvii.  p.  380. 

Vol.  I.— 31 


482  DISEASES  OF  THE   VULVA. 

but  even  where  the  sphincter  has  been  torn.     Permanent  fistulse,  due  to 
accidents  or  coitus,  are  to  be  treated  in  the  same  way  as  those  due  to  labor. 


Hernia. 

Women  are  liable  to  the  same  forms  of  hernia  that  are  found  in  men. 
Many  of  them  resemble  exactly,  in  symptomatology  and  treatment,  those 
found  in  the  male,  while  others  are  changed  in  some  particulars  by  the 
different  anatomical  conditions  existing  in  the  two  sexes.  But  besides 
those  which  they  have  in  common  with  men,  women  are  subject  to 
certain  peculiar  distinct  varieties. 

The  varieties  which  are  peculiar  to  women,  or  are  materially  modified 
by  the  anatomy  of  the  female  pelvis,  are — 

1.  Inguinal  or  suprapubic  hernia. 

2.  Elytrocele,  or  vaginal  hernia. 

3.  Pudendal  hernia. 

4.  Cystocele,  or  hernia  of  the  bladder. 

5.  Rectocele,  or  hernia  of  the  rectum. 

6.  Perineocele,  or  perineal  hernia. 

1.  Inguinal  Hernia  (Anterior  Labial  Hernia,  Episiocele). 
— Portions  of  the  abdominal  contents  may  come  down  through  the 
abdominal  ring  into  the  labium  majus  in  the  female,  in  a  manner 
exactly  analogous  to  scrotal  hernia  in  the  male.  The  treatment  is 
practically  the  same,  whether  by  truss  or  radical  operation ;  but  the 
diagnosis  presents  some  peculiar  features.  Early  in  its  descent  the 
hernia  makes  a  small  tumor  in  the  region  of  the  external  abdom- 
inal ring.  It  gradually  pushes  its  way  down  into  the  labium  majus, 
where  it  makes  a  swelling  of  the  part.  Such  a  hernia  may  occur  on 
one  side  alone,  or  there  may  be  one  on  each  side  at  the  same  time. 

Diagnosis. — Early  in  its  career,  a  hernia  is  liable  to  be  confounded 
with  diseases  of  the  round  ligament,  or  accumulations  in  the  canal  of 
ISTuck.  Later  on  it  may  be  mistaken  for  cysts  or  abscesses  in  the 
labium,  cyst  or  abscess  of  the  recto-vaginal  gland,  and  tumors  in  the 
labia.  It  must  not  be  forgotten,  that  the  ovary  may  make  a  part  of 
the  contents  of  the  hernial  sac,  giving  it  a  density  and  a  painful  cha- 
racter entirely  unlike  other  forms  of  hernia.  Hernia  of  the  ovary  is 
often  congenital.  The  uterus  has  been  found  to  make  up  the  con- 
tents of  a  hernial  sac;  and,  pregnancy  occurring,  laparo-hysterotomy 
was  necessary  to  accomplish  delivery.  Two  such  cases  are  quoted  by 
Winckel.  A  careful  attention  to  the  general  rules  for  diagnosing  her- 
nia will  serve  to  distinguish  it  from  the  diseases  mentioned. 

Inguinal,  as  well  as  umbilical  hernise,  are  not  uncommon  complica- 
tions of  ovarian  and  other  abdominal  tumors.  Advantage  may  be 
taken  of  an  ovariotomy  or  other  abdominal  section  to  cut  out  the  ring, 


inn:  MA.  4Hi] 

in  the  case  of  an  alxloniinal  i-ii|)(iii'c,  »ir  to  unite  the  edges  of  the  rin^r 
with  (•atii:nt  sutni-c  at'tci"  iVcshcniiiii-  its  cdiics,  TJic  dangers  of  the  major 
ojH'ration  arc  not  thus  materially  increased,  'flic  wi-iter  has  followed 
this  practice  in  several  instances  with  satisfactory  resnlts.' 

•2.  VA(iiNAL  Hkijnia  (Vacjinal  P^ntkuocklk,  Colkockm:,  or 
Elvtuocelk). — A  vaginal  hernia  may  he  defined  to  he  the  extrusion 
of  a  portion  of  the  ahdominal  contents  through  an  oj)ening  in  tlie  mus- 
enlar  coats  of  the  vaginal  walls,  the  })erit(jneal  and  mucous  membranes 
remaining  intact  and  covering  the  hernia.  The  existence  of  a  (hstinct 
rupture  in  the  muscular  coat  is  doubted  by  some,  and  there  is  no  post- 
mortem reeord  to  prove  it;  but  in  several  reported  eases,  the  presence 
of  a  distinct  ring  in  the  vaginal  wall,  with  only  a  thin  covering  to  the 
protruding  gut,  would  seem  to  point  very  decidedly  to  the  existence  of 
such  a  rupture,  in  some  cases  at  least. 

Came. — The  cause  is  sometime.s  a  sudden  i'all  or  jar  of  the  body,  or 
some  great  muscular  effort,  such  as  lifting,  or  straining  at  stool.  Prob- 
ably the  most  frequent  causes  are  pregnancy  and  parturition.  The 
physiological  softening  of  the  tissue  Avhieh  takes  place  at  this  time 
prc^lisposes  to  the  rupture,  and  is  aided  by  the  increased  pressure  on 
the  pelvic  floor,  and  the  still  greater  increase  of  intra-abdominal  pres- 
sure during  the  pains,  especially  if  the  labor  be  long  and  severe.  Sir 
Astley  Cooper  believed  that  the  reason  of  the  comparative  rarity  of  this 
form  of  hernia  is  that  the  oblique  portion  of  the  pelvis  is  unfavorable 
to  its  production.  In  the  erect,  as  well  as  in  the  sitting  posture,  the 
intestines  fall  rather  upon  the  symphysis  pubis  than  upon  the  uterus 
and  the  parts  behind  it.  The  uterus  is  then  pushed  toward  the  rectum, 
and  Douglas's  cul-de-sac  closed.  Were  the  intestine  commonly  found 
filling  the  cul-de-sac,  undoubtedly  this  form  of  hernia  would  be  much 
more  common. 

The  situation  of  the  ring  or  opening  is  usually  behind  the  uterus ;  but 
cases  have  been  described  where  it  was  lateral,  or  even  anterior  to  the 
uterus.  These  latter  cases  greatly  resemble  pudendal  hernia.  A  case 
which  recently  occurred  in  the  practice  of  Dr.  W.  H.  Heath  of  Buffalo 
was  of  this  nature  (Fig.  177).  The  hernia  came  down  in  front  of  the 
uterus,  which  was  retroverted,  pushing  the  vaginal  walls  before  it  until 
it  presented  a  considerable  tumor  at  the  vulva.  The  mass  was  easily 
rethiced,  and  I  succeeded  in  retaining  it  in  place  by  a  Hofmanu's 
pessarv. 

Si/mptoms. — The  symptoms  are,  when  the  hernia  occurs  suddenh-,  a 
sense  of  something  giving  way,  followed  by  pain  and  a  feeling  of  ful- 
ness in  the  vagina.  The  pain  may  be  intense  and  alarming,  or  very 
slight  at  first.     AVhen  the  trouble  develops  slowly,  there  will  be  more 

^  For  a  fuller  consideration  of  those  classes  which  resemble  those  found  in  the  male, 
the  reader  is  referred  to  the  works  on  general  suriierv. 


484 


DISEASES  OF  THE    VULVA. 


or  less  interference  with  locomotion,  pain  on  coitus,  bearing-down  and 
often  colicky  pains,  with  constipation.  In  one  case  (Barker)  there  were 
numerous  attacks  of  sudden  and  severe  j)ain  with  all  the  symptoms  of 
peritonitis,  evidently  due  to  some  spasmodic  contraction  at  the  neck  of 
the  sac.     The  pain  yielded  to  morphine  and  other  treatment,  and  the 

Fig.  177. 


Anterior  Vaginal  Hernia. 

patient  made  a  good  recovery.  The  function  of  the  bowel  is  often 
interfered  with,  though  no  case  of  actual  strangulation  has  come  to 
my  knowledge.  Thomas  has  pointed  out  that  it  may  occur,  as  a  result 
of  pressure  in  labor,  from  inflammation,  fecal  impaction,  torsion  of  the 
contents  of  the  sac,  or  the  presence  of  a  tumor. 

During  labor  the  pain  caused  by  the  presence  of  the  gut  in  advance 
of  the  foetal  head  may  be  sufficient  to  stop  the  labor,  and  be  accom- 
panied with  all  the  symptoms  of  shock.  There  will  then  be  found  a 
characteristic  tumor  in  the  vagina,  or  such  a  tumor  may  appear  at  the 
vulva. 

Diagnosis. — The  diagnosis  must  depend  on  finding  the  hernial  pro- 
trusion within  the  vagina,  or  outside  the  vulva.  It  must  be  differen- 
tiated from  tumors  of  the  uterus  and  vaginal  wall,  solid,  cystic,  or  gas- 
eous. From  solid  tumors  it  could  be  distinguished  by  its  consistency, 
the  hernia  being  soft  and  yielding.  The  presence  of  an  enlarged  ovary 
or  small  pedunculated  fibroid  in  the  sac,  might  greatly  increase  the  dif- 
ficulties of  the  diagnosis.  The  peculiar  characteristic  would  be  the 
ability  to  reduce  it,  especially  with  the  patient  in  the  knee-chest  posi- 


iu:i:MA.  485 

tioii.  'riicrc  would  also  be  iin|nil>('  on  <'oii<;liiiitr  and  incrca'^c  of  tin- 
liinior  on  strainini:.  Intestine  in  the  .-ae  niiulil  liive  a  sense  oi'  jrni- 
ulihLi'  to  the  tiMich  ami  le-dHMhci'  on  |)cren.~--ion,  thoii;^h  it  is  (o  In- 
remembered  tlial  ^as  and  Ihiid  are  \>y  no  means  eonstantlv  loinid  in 
the  small    intestine. 

The  tnnioi-  is  nsnally  |icar— haix'd,  ni-uwiiiM  .-mailer  n|i\\ar<l,  thus 
resembjiiii;-  a  ]toly|)iis.  It  may  I'c-aeh  the  si/e  of  a  lletal  head  at  the 
very  outset,  thoiiuh  ii'enerally  quite  small.  It  must  be  remembered  that 
thesae  may  contain,  besides  intestine, omentum  and  fluid.  ( )nocase*  i.s  re- 
ported where  the  tumor  was  mistaken  for  a  juilypus  and  icmoved,  witli, 
of  eourse,  fatal  results.  To  make  sure  that  it  is  not  a  prolajise  of  tiie 
rectum  throuuh  the  vaiiinal  wall,  the  rectum  mav  be  fdled  with  water, 
or  a  combined  vauinal  and  rectal  examination  made.  The  e<1t:e  of  the 
hernial  sac  or  the  rin<i-  is  sometimes  to  be  distinctly  felt,  but,  when 
recent,  or  before  induration  has  taken  j)lace,  is  not  alwavs  discoverable. 

The  aspirator  needle  mi<iht  atlbrd  valuable  confirmation  in  cases  of 
doubt.  Should  the  ui'inary  bladder  make  part  of  the  hernia,  imperfect 
emi)tyino:  might  lead  to  cystitis.  In  tliis  case,  examination  by  the  sound 
or  Hn-icr  throntrh  tlie  urethra  would  l)e  indicated,  if  doubt  shoidd  exist, 

Trcatinnd. — In  the  way  of  treatment  the  first  thino;  is,  of  course,  to 
reduce  the  rupture.  This  may  be  done  by  taxi.s,  and  will  be  greatly 
aided  l)y  jiuttingthe  patient  in  the  knee-chest  position.  Should  this  fail 
and  the  symptoms  be  urgent,  the  whole  hand  might  be  introduced  into  the 
ret^tuni  and  the  mass  pulled  back  through  the  opening.  There  is,  how- 
ever, a.s  has  been  already  explained,  little  danger  of  strangulatiou.  The 
pain  in  the  acute  cases  may  l)e  relieved  by  morjihine,  or,  if  severe  enough 
to  warrant  it,  by  inhalations  of  chloroform.  If  it  occur  or  is  found  to 
exist  during  labor,  the  intestines  must  be  reduced,  and  held  back  bv  the 
hand,  until  the  presenting  part  has  passed  the  ])oint  of  escape.  If  this 
be  impossible,  the  labor  should  be  expedited  by  forceps  or  rapid  extrac- 
tion. After  the  reduction  of  the  rupture  in  the  non-pregnant  condition, 
an  effort  must  be  made  to  hold  it  up  by  a  pessary  or  supporter  of  some 
kind.  A  sponge  has  been  used  with  success,  the  patient  introducing  it 
before  rising  in  the  mornimr-  ^<>  Y\\\e  can  be  given  as  to  the  sort  of 
pessars'  to  be  used,  as  this  must  depend  entirely  on  the  situation  of  the 
rin<r.  If  the  opening  be  high  behind  the  uterus  in  the  posterior  fornix, 
a  permanent  cure  might  be  effected  by  obliterating  the  fornix  by  a  ]>lastic 
operation,  uniting  the  ])osterior  wall  of  the  cervix  with  the  jiosterior  \\all 
of  the  vagina  to  a  point  below  the  opening,  great  care  being  taken  not 
to  open  into  the  peritoneal  cavity  while  denuding  the  tissue.  Should 
relief  be  unattainable  in  any  other  Avay,  tiie  sac  might  be  oj)ened  and 
the  edges  of  the  ring,  if  there  be  any,  united  bv  suture.  If  done  with 
proper  precautions,  the  danger  would  l)e  but  slight. 
1  Cenlralblatt  f.  Gyn.,  vol.  iii.  p.  103. 


486  DISEASES   OF  THE   VULVA. 

Dr.  Thomas  proposed^  and  successfully  carried  out  a  novel  plan  in 
the  case  of  a  large  hernia  which  was  causing  the  patient  very  great  dis- 
tress. He  made  an  abdominal  section,  and  after  emptying  the  sac  and 
inverting  it,  j)ulled  it  up  and  fastened  it  to  the  abdominal  wound,  sus- 
taining it  by  two  needles,  in  the  same  way  that  the  stump  is  held  up  in 
hysterectomy.  He  found  a  large,  soft,  subperitoneal  fibroid  tumor  of 
the  pelvic  connective  tissue  which  had  made  part  of  the  contents  of  the 
sac.     This  was  removed  at  the  same  time. 

In  cases  occurring  during  labor,  a  prolonged  and  unremitting  observ- 
ance of  the  recumbent  posture  during  convalescence,  has  several  times 
been  found  to  be  all-sufficient  to  eifect  a  permanent  cure. 

3.  Pudendal  Hernia  (Heenia  Labialis  Posterior,  Hernia 
Vagino-labialis). — These  names  are  given  to  that  form  of  hernia, 
in  which  the  rupture  appears  in  the  posterior  part  of  the  labium  majus. 
The  escaping  portion  of  the  abdominal  contents  makes  its  way  in  front 
of  the  uterus,  alongside  the  vagina  and  bladder,  and  between  them  and 
the  levator  ani  muscle,  through  the  pelvic  fascia,  and  finally,  passing 
through  the  pelvic  outlet,  enters  the  lower  portion  of  the  labium  majus, 
where  it  presents  as  an  elastic  swelling.  The  course  of  the  hernia  is 
just  along  the  ascending  ramus  of  the  ischium. 

This  form  of  hernia  is  rare,  but  seems  to  be  more  common  than 
true  vaginal  hernia.  The  sac  usually  contains  small  intestine;  but 
the  large  intestine  and  omentum  may  be  present  in  it,  and  in  a  case 
described  by  Hodgen  there  was  a  large  accumulation  of  fluid.  The 
size  of  the  tumor  is  not  usually  great — as  large  as  a  pigeon's  egg — but 
in  Hodgen's  case  the  mass  weighed  ninety-four  pounds.  In  shape  the 
hernia  is  pyriform.  It  usually  increases  gradually  in  size,  and  does  not 
bear  so  constant  a  relation  to  pregnancy  as  the  vaginal  form,  though  the 
relationship  is  retained  to  a  degree.  There  is  little  or  no  pain  accom- 
panying it  unless  it  reaches  a  great  size.  The  escaping  gut  is  usually 
easily  reducible,  and  often  goes  back  when  the  patient  reclines.  It 
enlarges  on  coughing  and  bearing  down. 

Diagnosis. — This  form  of  hernia  is  differentiated  from .  an  inguinal 
hernia  which  has  descended  into  the  labium  by  its  position,  being  much 
farther  back.  On  following  up  the  hernia  as  it  returns  into  the  peri- 
toneal cavity,  the  finger  will  pass  into  the  vagina.  The  upper  part  of 
the  labium  and  the  external  abdominal  ring  are  free,  and  pressure  made 
on  this  point  will  not  hinder  recurrence  of  the  tumor.  As  regards  its 
diagnosis  from  other  tumors  and  enlargements,  the  same  rules  apply, 
which  decide  us  in  any  form  of  hernia.  It  may  be  mistaken  for  a 
hydrocele  of  the  round  ligament,  new  growths  in  the  labium,  and  for 
hsematoma  and  abscess  of  the  vulvo-vaginal  glands.  In  both  cases 
the  history,  together  with  the  position  of  the  enlargement,  its  persistence 

'  iV.  Y.  Med.  Journ.,  Dec.  26,  1885. 


ni:i:.\/.i.  487 

under  niaiiipiilation,  and  tlic  absence  of  llie  nsnal  siiriis  <•('  iicniia,  niav 
he  relied  upon.  I 'n(|iiesti()nal)ly,  the  Lli'eatest  <lan<;ei-,  as  Tliomas  jHtints 
(lilt,  is  ill  llirLictlini;  llie  possihihty  of  hernia  in  this  position,  and  (h'aw- 
in«;-  dethietions  withont  eonsiderinj:,-  it.  The  re.-iilt.-  of  siieli  a  ini-lal^f 
niiiiht   perhaps  hi-  (hsasti'ons. 

Tiu  ((hill  III. — The  treatiiieiit  of  tiiis  hernia  is  e->eiitiall\'  (hllieiih. 
As  in  vaginal  hernia,  a  |)essai'\  wuin  in  the  va<iina  may  he  siillieient 
to  retain  the  intestine  in  phiee,  hut  many  ol»staeles  stand  in  the  wav 
ot'  siieeess.  A  truss  ])ri)periy  adjii.-ted,  or  a  T  l)an<la<re,  niav  he  snfti- 
eient.  In  every  ease  an  eH'ort  sliouhl  he  made  to  suj)])oi-t  the  hernia, 
as  it  may  become  <ji:reatly  enlarged,  and  j)ro(hiee  serious  trouble  or 
even  death  (Hotluen).  There  are,  apparently,  no  eases  of  irreduei- 
ble  hernia  ol"  this  class,  thoutyh  symptoms  of  straufrulation  may  (x-eur. 
Taxis,  aided  by  the  knee-chest  position,  Avill  probably  cause  the  mass 
to  return  in  every  case.  There  is  little  chance  of  a  cure  by  radi- 
cal operative  measures ;  as  the  exact  situation  of  the  neck  of  the  sac 
would  be  hard  to  determine,  and  would  probably  be  too  hi<rh  to  be 
easily  reached,  except  by  laparotomy.  Thomas's  operation  miiiht  be 
apjilicable  to  a  case  of  this  kind,  should  the  symptoms  warrant  it.  In 
a  case  observed  and  described  by  Winckel,^  lie  succeeded  in  holdinu;  uj) 
the  hernia  by  first  freshening  the  periphery  of  the  surface  over  the  rup- 
ture for  about  1.5  cm.,  and  rein  verting  this  portion  by  sutures.  After 
iniion  had  taken  place  the  thinned  and  dilated  skin  was  much  thicker, 
contracted,  and  more  resistant ;  and  a  carefully  applied  truss,  Avhich 
before  was  useless,  now  gave  a  good  result.  A  truss  made  on  the  plan 
of  a  T  bandage,  with  an  upright,  holding  a  pad  or  cup-shaped  sujiport, 
would  seem  most  likely  to  succeed. 

4.  Cystocele  (Hernia  of  the  Bladder). — This  consists  of  a 
prolapse  of  the  anterior  wall  of  the  vagina,  carrying  with  it  the  closely- 
attached  bladder.  It  is  usually  clue  to  some  lesion  of  the  pelvic  floor 
in  childbirth.^ 

5.  Rectocele  (Hernia  of  the  Rectum). — This  is  a  condition 
affecting  the  posterior  wall  of  the  vagina  and  rectum,  analogous  to 
cystocele.^ 

n.  Perineal  Hernia  (Perineocele). — Many  writers  describe  a 
form  of  hernia  in  which  the  intestines  make  their  way  first  into  Douglas's 
cul-de-sac,  and  then  force  a  passage  through  the  ])erineum  between  the 
vagina  and  rectum,  a]>pearing  as  a  tumor  near  the  anus.  In  the  male 
such  a  hernia  is  doubtless  possible ;  but,  after  a  careful  examination  of 
all  the  accessilile  literature  on  the  subject,  I  am  convinced,  that  in  the 
female,  such  a  hernia  is  impossible  and  never  existed.     The  testimony 

»  Pathol,  d.  Weibi  Sex.  Org.,  1881,  p.  282. 

^  For  full  description  see  article  on  the  Vagina,  Vol.  II. 

'  See  articles  on  the  Perineum,  Vol.  II. 


488  DISEASES  OF  THE   VULVA. 

of  the  older  writers  must  be  thrown  out,  as  they  did  not  sufficiently 
distinguish  a  rectocele  with  ruptured  perineum,  cystocele,  etc.  Many 
of  the  cases  are  too  im23erfectly  described,  and  some  of  them  were  not 
true  perineal  hernia,  but  simply  a  prolapse  of  the  intestine  into  Doug- 
las's pouch.  Pirogoff  has  described  a  case  (see  article  on  Anatomy)  in 
which  this  pouch  descended  to  the  floor  of  the  pelvis,  between  the  whole 
length  of  the  vagina  and  the  rectum.  Supposing  such  a  condition,  and 
a  displacement  of  the  uterus  toward  the  symphysis  pubis  so  that  the 
entrance  to  the  pouch  is  brought  well  forward,  a  prolapse  of  the  intes- 
tines might  readily  follow.  But  that  the  perineum  could  be  penetrated 
by  the  descending  gut  is  hardly  possible,  considering  its  dense  structure 
and  the  soft  and  easily  displaced  vaginal  and  rectal  walls,  by  which  it 
is  confined  before  and  behind.  The  point  of  least  resistance  would  be 
through  the  vulvar  opening,  displacing  the  vaginal  wall  and  the  peri- 
neum before  it.  No  modern  authority,  with  whom  I  am  familiar,  has 
seen  and  reported  a  case,  and  the  later  medical  journals  have  been 
searched  in  vain.  The  term  "perineal  hernia"  has  been  applied  to 
the  condition  which  is  here  described  as  pudendal  hernia,  and  this  is 
one  source  of  confusion  and  error.  Since  writing  the  above  I  have 
had  access  to  Winckel's  splendid  work  on  the  pathology  of  the  female 
organs,  and  he  takes  much  the  same  ground  as  is  here  taken  against 
the  existence  of  such  a  rupture,  and  considers  that  it  is  certainly  not 
proved. 

Prolapse  of  the  intestine  into  an  unusually  deep  Douglas's  pouch  is 
very  rare.  It  may  give  rise  when  it  occurs  to  many  disagreeable  symp- 
toms, such  as  fulness,  constipation,  and  colicky  pain.  It  may  be  easily 
recognized  by  conjoint  examination  in  the  vagina  and  rectum.  The 
intestine  is  easily  replaced,  and  may  be  kept  in  place  by  a  retroversion 
pessary — one  with  a  large  bulbous  extremity  best  filling  the  space  and 
keeping  the  intestine  in  place.  A  patient  wearing  a  pessary  for  such 
a  condition,  should  be  cautioned  against  a  possible  strangulation  by  the 
intestine  slipping  by  the  pessary  and  being  unduly  pressed  upon. 

Hydrocele  (H.  muliebris,  Cyst  of  the  Round  Ligament). 

These  terms  are  applied  to  a  collection  of  fluid  in  the  canal  of  ISTuck. 
The  condition  is  a  very  rare  one  ;  and  until  quite  recently  the  literature 
of  the  subject  has  been  very  scanty,  Hart,  Thomas,  Wile,  and  Hennig 
being  among  the  first  to  draw  attention  to  it.  Many  of  the  textbooks 
are  silent  on  the  subject.  About  fifty  cases  in  all  have  been  so  far 
described. 

The  canal  of  Nuck  is  usually  obliterated  before  birth,  but  occasion- 
ally the  whole  or  a  part  may  remain  open.  If  the  whole  is  open, 
affording  a  connection  with  the  abdominal  cavity,  the  result  may  be  the 


csca]M'  into  it  of  some  ol"  tlu'  :il)(l<iiiiiiial  contents,  citlicr  intestinal  or 
Hniil.  If  only  a  |iail  rmiains  open,  the  opcniiiL;  ;il  tlir  lan^;  Ix'inu 
closed,  the  niemWranc  nia\'  take  on  a  secretorv  action,  resultinf;  in  the 
i'orniation  of  a  cy.-^l.  The  <'an>e  ol"  this  condition  i>  little  nndcr^tood. 
Tniumatisni,  {)re<;-nancy,  and  lahoV  ha\-e  hecn  thonLiht  in  a  few  ea>c>  to 
luivo  had  some  share  in  its  prodnction,  hnt  in  the  niajoritv  ol"  ca,-(s  no 
cause  lias  l)een  assiiiiied,  "^riie  llnid  is  usnally  of  a  |)ale  straw  color,  con- 
taining albumen,  salts,  and  e])ithelial  cell>,  and  occasionally  hlood, 
Karoly,  pus  and  o-as  are  found  as  the  residt  ol'  inllannnation,  or  septic 
inoculation  of  the  cyst. 

This  disease  lias  been  found  in  all  periods  of  life,  from  two  to  seven- 
ty-oni'  years.  It  is  rather  more  common  on  the  ritrht  side  than  on  the 
left,  and  in  a  few  instances  both  sides  have  been  affected. 

S//iit])(oins. — The  clinical  history  of  the  disease  is  very  short.  It 
usnally  lH>>;'ins  as  a  painless  swellinjj;  in  the  neighborhood  of  the 
external  abdoniinal  ring.  This  swelling  grows  slowly,  and  gives  little 
inconvenienee  until  it  reaches  considerable  sizc.^  It  may  finally  enlarge 
to  the  size  of  a  child's  head,  or  may  never  exceed  that  of  a  marble. 
Dyspareunia,  sterility,  and  interference  with  locomotion,  as  well  as 
reflex  nervous  symptoms,  may  be  the  only  results.  In  a  few  instances 
inflammation  has  resulted  either  from  surgical  interference  or  from  too 
great  expansion  of  the  sac.  Erysipelas  has  several  times  followed 
operative  procedures. 

Diagnosis. — The  diagnosis  should  not  be  difficult  except  in  certain 
complicated  cases,  and  yet  the  mistake  has  frequently  been  made  of 
confounding  it  with  a  rupture,  particularly  with  strangulated  hernia. 
The  situation  of  the  tumor,  just  below  the  abdominal  ring,  or  in  the 
labium  majus,  if  large,  might  lead  to  such  a  mistake ;  but  the  history 
of  the  case,  its  long  duration  (years  in  many  cases),  the  fact  that  it  can- 
not be  and  never  has  been  reducible,  absence  of  impulse  in  coughing, 
and,  finally  the  light  test,  as  in  hydrocele  in  men, — may  serve  to  dis- 
tinguish it  in  unct)mplieated  cases.  The  peculiar  feel  of  water  in  a 
tense  sac,  should  serve  as  an  aid  to  the  experienced  touch,  and  would 
be  quite  different  from  that  presented  by  intestine  or  omentum  in  a 
hernial  sac.  In  cases  complicated  by  inflammation,  where  the  cyst 
contains  pus  or  blood  and  gas,  the  diagnosis  will  be  more  difficult.  It 
is  not  to  be  forgotten  also  that  a  hydrocele  and  a  hernia  may  coexist. 
In  doubtful  cases  puncture  with  an  aspirator-needle  is  not  only  safe,  l)ut 
necessary  for  the  establishment  of  a  certain  diagnosis.  To  distinguish 
a  bad  case,  with  fever  and  vomiting,  from  strangulated  hernia,  the 
absence  of  obstipation  should  be  conclusive.  To  diagnose  this  disease 
from  cysts  in  other  parts  of  the  labia  is  difficult,  but,  fortunately,  of 
little  practical  moment,  as  the  treatment  would  be  the  same  in  any  ease. 

'  See  case  of  Dr.  Baker,  p.  535. 


490  DISEASES  OF  THE   VULVA. 

Treatment. — The  treatment  must  be  varied  according  to  the  case.  If 
the  fluid  can  be  returned  to  the  abdominal  cavity  by  taxis,  this  should  be 
done,  and  the  pressure  of  a  truss  may  then  suffice  to  cause  adhesive  inflam- 
mation, and  obliteration  of  the  sac.  In  case  the  fluid  is  encysted,  simple 
puncture  may  be  enough  to  effect  a  cure,  but  usually  something  more  is 
required.  If,  after  evacuation,  an  irritant  is  injected  into  the  sac,  inflam- 
mation will  be  set  up  and  a  cure  effected.  For  this  purpose  a  few  drops 
of  tincture  of  iodine  or  carbolic  acid  have  been  successfully  used.  In 
other  cases  it  has  been  found  better  to  lay  the  whole  sac  open,  pack  it 
with  lint,  and  allow  it  to  e-ranulate  and  heal  from  the  bottom.  In  case 
of  suppuration  of  the  sac,  a  free  incision  and  packing  with  lint  and  iodo- 
form, or  some  similar  antiseptic,  is  certainly  indicated.  Hening  cured 
one  case  with  an  iron  wire,  carried  through  the  cyst  and  left  for  some 
time.  After  simple  evacuation  care  should  be  taken  not  to  manipulate 
the  parts  too  much,  so  as  to  set  up  inflammation  and  suppuration.  Per- 
fect rest  for  a  day  or  two,  with  moderate  pressure  from  a  compress  and 
bandage,  should  be  the  after-treatment.  In  this  disease,  as  in  several 
other  affections  of  the  vulva,  the  greatest  danger,  unquestionably,  lies 
in  a  wrong  diagnosis  and  consequent  improper  treatment. 

Vulvitis  (Inflammation  of  the  Vulva). 

There  are  five  forms  of  vulvitis  described — viz.  the  simple,  gonor- 
rhoeal,  follicular,  diphtheritic,  and  phlegmonous. 

Simple  Vulvitis. — Acute  catarrhal  vulvitis,  except  in  a  very  mild 
form,  is  a  rare  disease  in  the  adult ;  among  children  it  is  quite  com- 
mon. Nearly  all  cases  met  with  among  women  can  be  safely  classed 
under  the  head  of  specific  disease.  In  a  subacute  or  chronic  form  it  is 
more  common.  When  acute  and  non-specific,  it  is  generally  confined 
to  the  vulva  alone,  and  does  not  involve  the  vagina. 

The  causes  of  the  acute  form  are  injuries  and  operations,  awkward 
and  immoderate  coitus,  irritating  discharges,  and  want  of  cleanliness. 

The  first  symptoms  are  heat,  burning,  and  moderate  swelling  of  the 
parts,  with  redness  and  pain,  especially  on  motion.  This  is  followed 
by  a  free  secretion  of  muco-pus,  which  continues  for  a  time,  with  an 
abatement  of  the  symptoms. 

The  course  of  the  disease  is  usually  self-limited,  but  may  run  into 
the  chronic  form.  It  has  been  asserted  (Bedford)  that  this  disease  is 
contagious ;  but  of  this  we  have  no  proof,  and,  until  we  learn  more  cer- 
tain ways  of  distinguishing  this  disease  from  gonorrhoea,  we  can  neither 
deny  nor  confirm  the  assertion. 

The  causes  of  the  subacute  form  are  different.  Here  we  have  the 
irritating  discharges  from  the  vagina  playing  the  most  important  part. 
The  discharge  is  often  only  slight,  merely  sufficient  to  spot  or  stain  the 


VVLVITIS.  491 

liiKMi,  and  is  oltcn  oi'  a  ycllowisli  or  nivonisli  color,  and  of"  a  sti'ictlv 
imicoid  I'onsistciicv.  'I'lic  iiuicoiis  mcinliranc  may  he  soiiicwliat  swollen 
and  piiIlN ,  and,  in  lonL^-conlinncd  <-a.--i's,  nia\'  l)ci-oiiic  ulccratcfl.  1  )i;i- 
iK'tos  is  also  vi-ry  conunonly  a('coinj)anit'(l  by  vulvitis — so  nuicli  so  that 
its  continuod  presence  should  always  lead  to  the  examination  ol'  the 
urine  i'or  snuar.  It  slmidd  he  remembered  that  dialx'tes  may  exist 
without  |)olyuiMa,  and  is  olten  met  with  about  the  time  ot"  the  meno- 
j)ause.  The  vulvitis  oi"  diabetes  often  presents  a  ))eculiar  copj)erv-red 
color  (^W'inckel).  .Vmmoniaeal  ni'ine,  when  eoiul)ine<l  \\\\\\  inconti- 
nence or  a  vesico-va_<i'inal  iistula,  will  also  t!;reatly  irritate  the  mucous 
nuMubrane  which  is  constantly  l)atlied  with  it.  ^^'ant  of  cleanliness, 
es])ecially  in  very  hot  weather  and  in  very  lleshy  persons,  may  ])roduce 
the  tlisease.  Masturbation  and  excessive  vcnery  more  oiten  cause  this 
form  than  the  other.  AVhen  not  due  to  the  state  of  the  urine,  this  dis- 
ease is  comnionlv  found   in   unmarried,  and  especially  voung;,  women 

The  symptoms  are  more  or  less  burning  and  itching  of  the  parts, 
generally  intermittent,  worse  one  part  of  the  day  than  another,  and  the 
jiresenee  of  a  discharge.  The  constant  scratching  may  lead  to  the 
establishment  of  the  habit  of  masturbation. 

Treatment. — The  treatment  of  the  acute  form  must  consist,  first,  of 
rest  in  bed  until  the  acute  symptoms  have  passed.  General  treatment 
should  be  such  as  w-ould  tend  to  reduce  arterial  tension  and  allay 
excitement.  For  this  purpose  aconite  and  saline  laxatives  are  indi- 
cated, especially  if  there  be  any  fever.  Locally,  soothing  and  emollient 
applications,  together  with  strict  attention  to  cleanliness.  The  lead- 
and-opium  wash  is  very  generally  recommended  and  used.  Frequent 
ablutions  from  a  fountain  syringe  of  hot  boric-acid  solution,  followed 
by  dusting  the  parts  with  oxide  of  zinc  or  iodoform,  will  be  of  great 
service.  All  ointments  made  of  lard  or  animal  fats,  unless  containing 
an  antiseptic,  should  be  withheld  ;  as,  by  decomjiosition  of  the  fat,  they 
tend  to  increase  the  irritation.  Vaseline  thickened  with  wax,  or  lano- 
lin, is  a  suitable  base  for  ointments.  After  the  acute  stage  is  over, 
astringent  lotions,  such  as  mild  solutions  of  alum,  or  subacetate  of  lead, 
or  nitrate  of  silver,  may  be  used. 

In  the  subacute  form  great  care  should  be  taken  to  remove  all  irri- 
tating discharges.  If  the  urine  is  ammoniacal,  it  shoidd  be  rcndei'cd 
acid  by  the  use  of  benzoic  acid  (benzoate  of  amnion.,  gr.  x,  every  four 
hours).  Hot  douches  to  the  vagina,  and  cotton  balls  introduced  within 
the  vagina,  to  collect  and  keej)  l>ack  discharges,  are  also  of  great  bene- 
fit. For  local  applications  nothing  acts  so  quickly  and  beneficially,  as 
a  solution  of  silver  nitrate,  ten  grains  to  the  ounce,  brushed  over  the 
l^uis  every  day  or  every  other  day.  If  this  fails,  a  stronger  solution 
can  be  employed,  or  some  other  simple  astringent  used.     It  must  be 


492  DISEASES   OF  THE    VULVA. 

borne  in  mind,  however,  that  no  permanent  cure  can  be  effected  until 
the  irritating  discharge  is  stopped  at  its  point  of  origin. 

Diphtheritic  Vulvitis. — A  careful  search  has  brought  to  light 
no  recorded  cases  of  simple  primary  diphtheria  of  the  vulva  in  a  non- 
pregnant adult.  If  it  ever  occurs,  it  must  be  very  rare.  On  the  vulva 
and  vagina  of  children  it  is  sometimes  met  with  during  epidemics. 
Occurring  in  the  course  of  an  attack  having  its  primary  seat  elsewhere, 
or  in  the  course  of  one  of  the  exanthemata,  it  cannot  be  classed  as  a 
distinct  disease,  but  is  rather  an  epiphenomenon.  In  puerperal  women 
during  certain  epidemics  of  puerperal  fever,  especially  in  large  lying-in 
hospitals,  it  makes  up  a  considerable  part  of  the  local  lesions,  and  is  a 
very  dangerous  complication.  (The  reader  is  referred  to  Dr.  Lusk's 
excellent  paper  on  puerperal  fever  in  Pepper's  System  of  Medicine.) 

GoNORRHCEAL  VULVITIS. — As  this  is  but  a  single  factor  in  the  his- 
tory of  a  disease  involving  other  parts  as  well,  it  will  be  considered 
under  the  general  title  of  Gonorrhoea.  (See  Diseases  of  the  Vagina, 
Vol.  II.) 

Follicular  Vulvitis. — This  form  of  inflammation  affects  the 
sebaceous,  sweat-  and  hair-follicles,  which  are  so  freely  scattered  over 
the  labia  majora  and  minora.  The  mucous  follicles  of  the  vestibule, 
as  well  as  the  glands  of  Bartholin,  are  not  usually  affected.  The  disease 
is  fortunately  rare.  In  general  diffuse  inflammation  of  the  parts  the 
structures  named  are  affected,  but  in  the  disease  now  under  considera- 
tion they  are  the  sole  or  principal  part  diseased. 

Causes. — The  causes  are  usually  some  irritating  secretion  from  the 
vagina,  want  of  cleanliness,  leaving  the  secretions  between  the  folds 
of  the  parts  until  they  undergo  decomposition  and  become  irritating. 
Pregnancy  is  often  a  predisposing  cause. 

Symjjtoms. — The  symptoms  are  heat  and  burning,  and  above  all  itch- 
ing, of  the  parts.  The  irritating  character  of  the  discharge  from  the 
inflamed  glands,  as  well  as  any  previously  existing  discharge,  makes  an 
irritated  and  sensitive  condition  of  the  surrounding  surfaces.  This  is 
increased  by  the  constant  scratching  to  relieve  the  itching.  Secondary 
results  are  painful  micturition  and  dyspareunia. 

Pathological  Anatomy. — The  affected  glands  become  much  enlarged 
and  noticeable,  and  the  surface  around  them  red  and  swollen.  The 
mouths  of  the  glands  are  often  stopped,  the  secretions  are  retained, 
and  suppuration  takes  place.  The  glands  which  are  not  stopped  pour 
forth  a  quantity  of  thick  paste-like  secretion,  which  in  bad  cases  collects 
and  forms  a  thick  layer  in  the  folds  and  creases  of  the  membranes,  com- 
pletely covering  up  the  glands. 

Prognosis. — When  occurring  during  gestation,  the  disease  may  be  a 
serious  complication,  sometimes  resulting  in  abortion.  Fortunately, 
in  these  cases  it  usually  ends  with  the  pregnancy.     In  other  cases  it 


vri.viTis.  403 

iMMv  run  ;i  Imiii-  cniirsc,  jxnHliially  yielding;  to  trcatinciit  ;  or  mav,  if 
lU'-^lcctt  (I,  oi'  cNcii  ill  ~|>;tc  of  all  that  can  be  done,  run  on  in  tlic  clii'onic 
form.  It  may  then  Ixcoinc  a  really  I'orniidahlc  alTection,  rendcrinj;  tlio 
patient  nearly  or  (|iiite  in-aiie  iVoin  the  con-tant  irritation,  itehiiiu-,  and 
hurninii-  *d'  the  parts. 

Tnatijuiif. —  In  the  acute  iorm,  cl(aiilincss  is  tlu'  first  rc(|ui>ite.  If 
there  is  nuieh  vaginal  discharge,  this  must  be  first  relieved,  or  at  least 
kept  from  the  parts,  l)y  pledo-ets  of  dry  absorbent  cotton  pushed  into 
the  mouth  of  the  vaiiina  and  fmpiently  ehan«2;ed,  tog:ether  with  fre- 
(pient  vauinal  injections,  to  wash  away  the  discharge,  as  well  as  to  cure 
the  vauinal  disease  on  which  the  discharge  depends.  As  local  apjilica- 
tions,  hot  sitz-baths  (75°  to  80°  F.)  and  the  frequent  washing  of  the 
parts  with  very  hot  solutions  of  borax,  alum,  or  carbolic  acid  (1  :  40  or 
stronger)  may  accomplish  a  good  deal.  In  the  more  chronic  forms,  solu- 
tions of  nitrate  of  silver,  10-15  grains  to  the  ounce,  will  be  of  great  use. 
Persulphate  of  iron  in  weak  solution  has  been  recommended.  Oint- 
ments, Avith  vaseline,  or  vaseline  and  wax  (oj  to  .5j)  as  a  Ijase,  may  be  used, 
nuHlicated  with  subacetatc  of  lead,  bismuth,  oxide  of  zinc,  salicylic  acid, 
or  iodoform,  and  should  be  kept  constantly  smeared  over  the  parts.  In 
very  bad  chronic  cases,  strong  solutions  of  silver  nitrate  (.5j  to  ,5j)  may  be 
used,  after  a  thorough  cleansing  of  the  parts  ^vith  soap  and  Mater.  In 
extreme  cases  the  removal  of  the  entire  mucous  membrane  affected,  has 
been  resorted  to.  Great  attention  should  be  paid  to  the  general  health 
and  nutrition.  Tonics,  cod-liver  oil,  and  similar  preparations  should 
be  used.  The  use  of  narcotics  to  quiet  pain  and  produce  sleep  is 
attcMided  with  great  danger,  from  the  tendency  to  rely  u])on  them,  and 
thus  form  a  habit.  Opium,  in  particular,  and  chloral  should  be  Avitli- 
held  until  the  case  is  found  to  be  hopeless.  This  applies  as  well  to 
])ruritus,  eczema,  and  other  diseases  attended  with  itching  and  con- 
seijuent  sleeplessness. 

Phlegmonous  Inflammation  of  the  Vulva. — This  consists  in 
an  inflammation  affecting  the  connective  tissue  of  one  or  both  labia. 
It  may  follow  a  simple  catarrhal  inflammation,  or  be  caused  by  mechan- 
ical violence.  Prostitutes  are  peculiarly  liable  to  this  disease,  and  all 
the  cases  with  which  I  have  met  have  been  among  this  class.  After 
lasting  a  Aveek  or  ten  days  the  inflammation  may  subside,  or  it  may 
result  earlier  in  suppuration.  In  this  way  deep  abscesses  may  form, 
and  considerable  sloughs  come  away.  In  other  cases  the  disease  seems 
more  closely  allied  to  the  furuncular  process.  Hildebrandt  states,  that 
many  deep  abscesses  opening  on  the  vulva,  have  their  origin  in  the 
deeper  parts  of  the  pelvis,  from  parametritis,  bone  disease,  and  ulcer- 
ative processes  in  the  urethra  and  vagina.  With  this  statement  we  are 
unable  to  agree,  never  having  seen  any  cases  to  bear  out  this  view. 

The  treatment  of  simjile  inflammation  consists  in  hot  fomentations, 


494  DISEASES  OF  THE   VULVA. 

lead-and-opium  wash,  and  hot  sitz-baths.  Sulphide  of  calcium,  in 
small  doses  frequently  repeated,  has  the  reputation  of  warding  olf  sup- 
puration in  kindred  affections,  and  will  be  worthy  of  trial  here.  If 
matter  forms,  it  should  be  let  out  by  free  incision  as  soon  as  possible. 
The  hypodermic  injection  of  cocaine  has  served  an  excellent  purpose  in 
my  hands  in  deadening  the  pain  of  this  little  operation. 

FuRUNCULOSis  (Boils). 

Boils  on  and  around  the  vulva  are  not  very  uncommon.  They  often 
depend  on  some  constitutional  condition,  the  exact  nature  of  which  is 
not  well  understood.  They  sometimes  originate  in  an  inflammation  of 
the  sebaceous  or  hair-follicles,  and  then  closely  resemble  acne  in  the  start. 
They  are  distinguished  from  that  affection  by  their  size  and  number. 
The  irritation  caused  by  the  pulling  out  of  a  single  hair  may  be  the 
starting-point.  Poisonous  secretions  or  discharges  may  also  be  the 
exciting  cause.  When  resulting  from  a  general  cause,  they  are  apt  to 
be  persistent ;  occurring  in  successive  crops,  and  lasting  a  long  time. 
Some  will  suppurate  and  discharge ;  while  others  simply  swell  up,  and 
afterward  gradually  fade  away,  leaving  a  red  indurated  spot. 

Their  favorite  seat  is  the  outside  of  the  labia ;  but  occasionally  they 
extend  up  on  to  the  thigh,  or  over  the  mons  Veneris,  completely  dot- 
ting this  with  boils  in  various  stages  of  gro^^'th  and  decadence.  When 
occurring  singly,  they  sometimes  infiltrate  the  surrounding  tissues,  mak- 
ing a  large  abscess,  which  lasts  for  considerable  time  unless  opened  arti- 
ficially. 

Treatment. — This  should  be  both  general  and  local.  The  general 
treatment  should  be  of  a  restorative  nature — tonics,  cod-liver  oil,  and 
especially  the  hypophosphites,  which  seem  to  have  a  controlling  action 
on  the  dyscrasia.  The  sulphides  also  are  of  benefit.  As  to  local  treat- 
ment, the  removal  of  all  possible  sources  of  irritation  should  be  the 
first  thing.  When  the  boil  has  really  declared  itself,  early  incision, 
even  before  the  formation  of  pus,  will  abort  it.  This  can.be  done 
almost  painlessly  by  the  use  of  cocaine  hypodermically.  A  rather  free 
incision  should  be  made,  and  then  followed  by  an  antiseptic  lotion  on 
a  compress.  In  some  cases  it  has  been  recommended  to  touch  the  cut 
surfaces  with  carbolic  acid  and  glycerin,  equal  parts,  or  nitrate  of  silver. 
The  object  of  this  doubtless  is  to  prevent  absorption  by  the  raw  surfaces. 
After  pus  has  formed  incision  and  poultices  are  indicated. 

Ulceration  and  Fissure  op  the  Vulva. 

Specific  Ulceratiox. — Hard  and  soft  chancres  are  very  common 
among  prostitutes.  A  consideration  of  these  diseases  is  outside  of  the 
scope  of  this  work. 


fEDEMA    OF   Till-.    VllA'A.  A\)o 

NoN-siM'.cMic  rLCKii.VTloN  iiltlic  viilvji,  cxccpt  ill  cliildlu'd,  is  ;i 
ran' aflrcti"  111.  It  is  (K'CJisi(»ii;illy  in<l  \\  itli,  cspcciallv  aiimiij^- j)rostitiit('s, 
I'oriiiiiiL;  -mall  sensitive  scjrt's  artniixl  the  cut raiicc  ol'  the  vajiiiia  or  on 
tlic  liviiicii.  Ill  poorly-noiirislicd  wuiiicii  a  sli«ilit  rupture  (tf  tlic  pcri- 
11(11111  will  soiiictiiiu's  result  in  a  >iiiall  ji'rauulatiiijz;  surface  ()!•  nicer,  very 
tender  and  w  itli  sli<ilit  tendeney  tn  lical.  Tlic-c  |)ccnliar  ulcers  are  kept 
up  l)y  till'  tension  of  eieatrieial  hands  drauin^j;'  on  the  parts  with  the 
movements  of  the  patieut,  and  uu»y  be  so  sensitive  as  to  cause  <;reat 
sufferinj;-  and  entirely  prohibit  intereourse,  I  have  also  seen  ulceration 
around  the  clitoris  seemiugly  dependent  on  a  depressed  state  of  the 
"•eneral  svstem. 

Trvdiiiuiit. — As  it  is  easy  to  give  the  parts  perfect  physiological  rest, 
the  treatment  of  lissure  of  the  introitus  vaginae  is  comparatively  easy. 
By  securing  |)erfect  rest,  and  by  the  application  of  iodoform,  or  mcjder- 
ately  strong  solutions  (10  to  30  grs.  to  5j)  of  nitrate  of  silver,  bismuth, 
or  oxide  of  zinc,  the  disease  is  generally  quickly  cured.  In  the  case 
of  ulcers  dei)ending  on  cicatrices  fi-om  a  ruptured  perineum,  it  may  be 
necessary  to  cut  the  bands  which  pull  on  the  edges  of  the  sore,  and  thus 
give  the  parts  rest.  Usually  com]ilete  healing  then  rapidly  ensues. 
Severe  ulceration  sometimes  occurs  in  the  course  of  the  continued  fevers 
anil  in  wasting  disease. 

CEdema  of  the  Vulva. 

Owing  to  the  amount  of  loose  connective  tissue  in  and  around  the 
vulva,  these  parts  are  frequently  the  seat  of  oedema.  This  may  be 
inflammatory  in  its  origin,  as  in  phlegmonous  inflammation,  or  it  may 
be  only  a  symptom.  In  the  latter  case,  its  cause  must  be  looked  for 
either  in  some  general  condition,  a  disease  of  some  distant  organ,  or  in 
a  disease  in  the  pelvis  impeding  the  return  eircnlation.  Among  the 
general  conditions  causing  oedema  the  commonest  by  all  means  is  ]>reg- 
naney.  The  distant  (organs,  disease  of  which  gives  rise  to  oedema  in 
this  region,  are  the  same  as  those  causing  oedema  in  other  parts  of  the 
body  which  are  usually  coincidently  affected — viz.  the  kidneys,  heart, 
and  liver,  particularly  the  former.  In  the  last  stages  of  wasting  dis- 
ease it  is  not  uncommonly  met  with,  and  is  seen  also  in  cancer  of  the 
uterus  and  in  chronic  pelvic  inflammations.  Fibroid  and  ovarian 
tumors,  as  well  as  diseases  of  the  vagina,  are  sometimes,  though 
rarely,  accompanied  by  oedema  of  the  vuKa,  the  lower  extremities 
usually  being  affected  at  the  same  time.  The  swelling  may  become 
so  great  as  to  materially  interfere  with  the  comfort  of  the  patient.  In 
extreme  ca.ses  the  circulation  is  so  far  affected  that  gangrene  and  septic 
processes  may  follow'. 

Treatment  must,  in  the  main,  be  directed  to  the  general  condition 


496  DISEASES  OF  THE    VULVA. 

causing  the  oedema.  If  extreme  and  causing  suffering  with  danger  of 
sloughing,  multiple  punctures  may  become  necessary  to  relieve  the  ten- 
sion. This  procedure  is  not,  however,  without  danger ;  as  the  parts  are 
prone  to  take  on  inflammatory  action,  the  punctures  being  the  starting- 
points.  If  punctures  are  made,  antiseptic  washes  must  be  freely  used. 
Carefully-graduated  compression  with  a  pad  or  an  elastic  T  bandage 
may  be  of  service,  combined  with  the  recumbent  posture. 

Gangrene  of  the  Vulva. 

In  the  adult,  gangrene  is  usually  found  as  a  result  of  labor  with  pre- 
vious oedema,  or  of  some  mechanical  violence.  It  may  also  result  in 
non-pregnant  women  as  a  consequence  of  oedema,  thrombosis,  or  hsema- 
toma.  Several  cases  have  been  reported  where,  from  the  use  of  a  tam- 
pon wet  in  perchloride-of-iron  solution,  extreme  sloughing  of  the  vulva 
and  vao-ina  has  followed.  It  also  occurs  in  the  course  of  the  exanthe- 
mata,  preceded  usually  by  an  inflammatory  process. 

In  young  children  there  is  a  form  of  gangrene  which  is  held  by 
some  ^  to  be  identical  with  noma  and  hospital  gangrene.  The  disease, 
according  to  this  author,  is  contagious  and  iuoculable.  It  begins  as  a 
whitish  blister,  which  soon  changes  into  an  ulcer  and  grows  rapidly, 
the  surface  being  covered  with  a  soft  gray  or  brownish  membrane.  It 
resembles  diphtheria  in  some  respects,  but  can  be  distinguished  from  it. 
The  disease  is  local  in  its  origin.  The  affected  portion  becomes  gan- 
grenous, and  loss  of  substance  takes  place.  The  prognosis  is  bad,  gen- 
eral putrid  infection  usually  taking  place. 

Treatment. — In  the  ordinary  forms  the  principal  point  is  to  guard 
against  septicaemia.  To  this  end  all  sloughing  masses  must  be  cut 
away,  care  being  taken  not  to  cut  living  tissue  more  than  is  neces- 
sary. Where  fresh  tissues  are  cut,  the  mouths  of  the  vessels  must  be 
sealed  by  the  actual  cautery,  and  free  use  of  antiseptics  resorted  to. 
In  noma,  iodoform  is  claimed  to  act  as  a  specific ;  chlorate  of  potas- 
sium is  also  highly  recommended.  Internally,  tonics  and  stimulants 
must  be  freely  used,  and  the  strength  maintained  by  abundant  nour- 
ishment. 

Varicose  Veins  of  the  Vulva  (Phlebectasia). 
The  veins  of  the  vulva  may  be  permanently  dilated,  sometimes  form- 
ing immense  tumors  or  swellings.  This  affection  is  found  at  all  ages', 
though  rarely  among  the  young.  It  is  usually  related  more  or  less 
closely  to  pregnancy,  but  cases  have  been  observed  in  women  who  had 
never  been  pregnant.  I  have  met  with  one  such  case.  If  antedating 
pregnancy,  it  is  always  aggravated  at  that  time. 

^  Damien  Surjus,  lliese  de  Lyon,  1882. 


JLKMATOMA,    Oil    TllROMni'S   OF  Till:    VILVA.  497 

('(luxe. — A  contrt'iiital  <>r  ac<|iiirt'(l  thiniiiii<:-  of  tlic  walls  (iCllic  vciii.s 
must  be  supposed  ;  in  addition  to  this  an  increase  in  the  venons  pres- 
snre,  due  to  obstruction  of"  the  rctnrn  circnlation.  These  conditions  arc 
ni(»st  perfectly  fnllilied  in  pre<inancy,  and  we  find  the  disease  more 
<'onmion  at  that  time.  In  the  non-pregnant  tlie  same  e<»ndition  mav 
be  prcuhu'cd  bv  tumors,  also  bv  (obstinate  constipation  with  strainint:-  at 
st<tol  ( WincUcI),  Jjit'ting  heavv  weiulits,  the  constant  maintenance  ot" 
the  erect  posture,"  may  also  have  an  influence  in  causing  the  diflicultv. 

Syinptotns. — The  symptoms  are  the  presence  of  more  or  less  swelling 
of  the  external  genitals.  It  is  sometimes  confined  to  the  labia,  or  mav 
atftH't  the  nymplue,  the  mons,  and  inside  of  tiie  thighs  as  well.  One  or 
both  sides  may  be  affected.  Holden'  saw  a  ease  as  large  as  a  child's 
head.  The  swelling  is  usually  quite  irregular  in  outline,  and  the  tumor 
is  sofit  and  easily  compressible,  being  much  more  prominent  when  the 
patient  is  standing.  There  is  often  a  great  deal  of  heat  and  burning 
in  the  parts,  and  sometimes  obstinate  pruritus.  Rupture  may  take 
place  and  the  resulting  hemorrhage  be  quickly  fatal.  The  dangers 
of  rupture  are  increased  during  labor.  If  the  rupture  is  confined  to 
the  walls  of  the  veins,  and  the  skin  remains  intact,  a  hsematoma 
Mill  result. 

Treatment. — Remedies  directed  to  the  condition  of  the  veins  Mill 
accomplish  little.  Ergot,  hamamelis,  and  other  drugs,  used  both 
externally  and  internally,  have  entirely  failed  in  my  hands.  The 
M'earing  of  a  properly-constructed  pad  or  supporter  may  diminish  the 
tendencv  to  groMth,  and  in  one  case  under  mv care  certainlv  gave  great 
relief.  All  attempts  to  tie  the  veins  or  to  inject  astringents  into  them 
M'ould  be  certainly  useless.  If  pregnancy  should  occur  in  a  bad  case, 
abortion  in  the  early  months  Mould  seem  to  be  fully  justified.  The 
patient  must  be  Marned  of  the  danger  of  rupture  and  hemorrhage,  and 
told  of  the  proper  way  of  treating  herself  until  she  can  obtain  aid — 
viz.  by  assuming  the  recumbent  posture  and  making  direct  digital  pres- 
sure upon  the  bleeding  point,  or  by  a  pad  and  T  bandage  firmly  applied. 
This  treatment  may  be  supplemented  by  the  use  of  astringents,  by  com- 
pression M'ith  a  pad  outside  against  a  firm  tampon  inside  the  vagina 
and  vulva ;  or  the  parts  may  be  compressed  against  the  pubic  bone. 
If  a  large  tear  or  rupture  take  place,  such  as  might  occur  in  labor, 
bringing  the  parts  together  by  deep  sutures  may  be  necessary.  At  all 
times  constipation,  and  consequent  straining,  must  be  avoided. 

HEMATOMA,    OR   ThROMBUS    OF    THE    VuLVA. 

This  may  be  defined  to  be  an  efftision  of  blood  into  the  tissues  of  the 
vulva  from  the  rupture  of  a  vessel  beneath  the  surface.     The  vessel 

>  X  Y.  Med.  Record,  Julv,  1S68. 
Vol.  T.— 32 


498  DISEASES   OF  THE   VULVA. 

ruptured  is  usually  a  vein,  as  it  is  not  at  all  likely  that  an  artery  of 
any  size  could  be  ruptured  in  the  soft  tissues  in  which  they  are 
imbedded. 

The  causes  are  external  violence,  such  as  a  kick,  blow,  fall,  or  instru- 
mental delivery ;  and  violent  muscular  eifort,  as  in  labor,  or  straining  at 
stool.  The  predisposing  causes  are  pregnancy  and  varicose  veins,  but 
neither  of  these  is  necessary  for  the  occurrence  of  rupture. 

Symptoms. — When  rupture  takes  place  the  tumor  develops  rapidly. 
It  may  be  quite  small,  or  so  large  as  to  block  up  the  vagina  and 
urethra ;  and,  if  it  occur  during  labor,  it  may  be  a  barrier  to  the  pas- 
sage of  the  child.  The  seat  is  usually  in  the  labia  majora  or  in  the  parts 
near  the  clitoris.  Winckel  mentions  having  seen  the  blood  escape  into 
the  remains  of  the  hymen,  forming  a  tumor  as  large  as  a  bean  or  larger. 
If  the  tumor  is  small,  very  little  inconvenience  will  be  produced,  but 
absorption  will  generally  quickly  take  place.  In  the  case  of  a  large 
tumor  absorption  may  take  place ;  but  there  is  more  likelihood  of  sup- 
puration and  gangrene  of  the  parts.  The  tumor  then  swells,  becomes 
hot,  tender,  and  painful ;  the  skin  assumes  a  bluish  and  purplish  hue ; 
and  more  or  less  constitutional  disturbance  ensues.  Should  the  accident 
happen  near  the  end  of  pregnancy,  the  ensuing  labor  is  apt  to  cause 
either  a  renewal  of  the  hemorrhage,  or  gangrene  and  sloughing  of  the 
parts.  It  might  be  well,  should  a  large  swelling  exist  when  labor 
begins,  to  open  it  and  turn  out  the  clots. 

Treatment. — For  the  lesser  cases,  little  need  be  done  except  to  protect 
the  swollen  part  from  irritation.  Should  inflammation  threaten,  the 
persistent  application  of  cold  by^  the  ice-bag  or  rubber  coil  should  then 
be  tried;  should  the  symptoms  not  soon  show  an  improvement,  free 
incision  is  indicated.  It  must  not  be  forgotten  that  quite  threatening 
symptoms  may  be  abated  by  treatment ;  and,  on  the  other  hand,  after 
suppuration  has  once  begun,  the  earlier  the  incision  the  better.  When 
incision  is  made  all  the  clots  should  be  turned  out,  ragged  edges  trimmed 
off,  and  any  sloughing  tissues  removed.  Thorough  irrigation  of  the 
wound  with  an  antiseptic  solution  should  then  be  made,  the  surfaces 
sprinkled  with  iodoform,  and  the  cavity  packed  with  gauze  or  cotton. 
This  may  be  repeated  until  the  wound  is  healed.  Should  hemorrhage 
occur  after  opening,  it  can  be  stopped  by  pressure,  or  the  application  of 
alum  or  other  astringent.  (For  further  details  of  this  subject  the  reader 
is  referred  to  works  on  obstetrics,  to  which  it  more  properly  belongs.) 

Diseases  of  the  Vulvo -Vaginal  Gland. 

It  is  surprising  how  little  has  been  written  in  American  literature 
concerning  the  affections  of  these  glands ;  and  yet  Hildebrandt  declares 
them  to  be  among  the  most  common  affections  of  the  external  genitals 


jjj^L'Ash'.'^  (jf  rill-:  vri.Vd-VM.iXM,  <;lam).  49U 

— ail  (tj)iiiinii  ill  wliicli,  as  a|i|>lii:il)|c  to  a  ci  riaiii  das.-  dl'  sncict\-,  I  can 
a-ric". 

CaTAKKII  uF  the  Gl.AXns. —  II\  ixTscrrctiiiii  fioiii  flic  (flaiid  is 
rarely  observed.  Winekel  .states,  that  lie  lias  seen  tlie  disease  last  iiir 
iiidiitlis.  'i'lie  duet  is  then  dilatccl  so  that  a  sound  can  i)e  {)assed,  and 
a  viscid  niiieus  may  lie  i'orced  out  l)y  pressure.  It"  the  secretion  is  too 
thick  to  tlow  out,  the  mouth  ol*  the  tilaiid  may  heeoine  elosed  and  a 
retention-cyst  tbrnied.  Kricli '  has  reported  some  eases  of"  "  paroxvsms 
in  the  female  resemblin*!;  nocturnal  eiiiissioiis  in  the  male."  'i'liat  this 
does  (K'cur  1  can  also  testify,  havinji;  met  with  a  ease. 

The  treatment  of"  catarrh  of"  the  glands  is  very  unsatisfactory.  I  have 
succeeded  in  dilating-  the  duct  in  one  instance  and  injecting  strong 
solutions  of"  carbolic  acid  with  benefit.  In  case  nocturnal  ])ol]utions 
become  excessive,  so  as  to  weaken  the  individual,  af"ter  the  failure  of 
treatment  calculated  to  restore  the  general  health,  Winekel  has  pro- 
posed the  extirpation  of  the  gland. 

Inflammation  of  the  Duct. — The  excretory  duct  is  about  2  cm. 
long,  and  opens  just  in  front  of  the  hymen  or  its  remains,  A  fine  proljc 
can  generally  be  made  to  enter  it.  This  duct  may  become  obstructed 
by  inspissation  of  the  secretion  (catarrh),  but  this  generally  occurs  as  the 
result  of  an  acute  inflammation  of  the  nuicous  membrane  in  and  around 
the  mouth  of  the  duet.  It  may  be  obstructed  also  by  venereal  warts, 
either  in  the  duct  or  outside  near  its  mouth.  This  inflammation  may 
be  traumatic,  but  by  all  means  the  most  common  cause  is  gonorrhoeal 
infection.  As  the  result  of  the  retention  of  the  secretion,  or  of  the 
products  of  the  inflammation,  a  tumor  or  cyst  is  formed,  which  gradu- 
ally grows  until  sometimes  it  is  as  large  as  a  hen's  egg.  This  crowds 
toward  the  middle  line  and  obstructs  the  entrance  of  the  vagina.  Ac- 
cording to  Hildebrandt,^  as  the  distension  goes  on  a  point  is  finally 
reached  A\here,  through  the  distension  of  the  external  tissues,  the  duct 
is  easilv  opened;  so  that  the  secretions,  generally  pus,  make  their  Avay 
out,  and  the  tumor  collapses.  As  the  conditions  Avhich  originally 
caused  the  excessive  secretion  and  occlusion  still  exist,  the  sac  soon 
fills  again,  with  a  like  result.  Sometimes  an  acute  inflammation  of 
the  superimposed  and  adjacent  tissues  is  set  up,  attended  with  much 
pain  and  annoyance  to  the  patient. 

Usually,  the  course  of  the  disease  is  run  in  about  a  week. 

Diagnosis. — The  size  and  position  of  the  swelling,  just  outside  of  the 
vaginal  entrance,  its  superficial  seat,  and  perhaps  the  history  of  previous 
swelling  and  collapse,  with  a  discharge  of  mucus  or  pus,  will  serve  to 
distinguish  it  from  inflammation  and  abscess  of  the  gland  proper. 

Treatment. — The  treatment  should   be  begun  with  an  effort  to  re- 

'  Mnnihnd  Me-l  Joxrn.,  1882,  vol.  ix.  p.  348. 
^  Billroth'^  Handbuck  d.  Fraiwidrankheiten. 


500  DISEASES   OF  THE   VULVA. 

establish  the  natural  opening  of  the  clnct.  This  may  be  done  by  care- 
fully probing  the  canal,  and,  once  an  opening  is  found,  by  dilating  it 
with  graduated  sounds.  In  searching  for  the  opening  to  the  duct  it 
must  not  be  forgotten  that  there  are  two  or  more  mucous  follicles 
opening  in  its  immediate  neighborhood,  which  may  be  mistaken  for  it. 
If  warts  exist,  they  must  be  removed,  and  the  associated  gonorrhoea! 
vaginitis  cured.  If  it  be  found  impossible  to  discover  the  duct,  the 
swelling  may  be  opened  and  the  contents  evacuated.  If  it  again  fills, 
a  piece  may  be  cut  from  the  walls  of  the  cyst  with  scissors,  first  lifting 
the  wall  with  a  tenaculum,  so  as  to  make  a  permanent  opening.  The 
cyst  should  be  thoroughly  irrigated,  and  a  solution  of  silver  nitrate 
(3j— 5j)  be  injected  ;  or  the  cavity  painted  out  with  strong  tincture  of 
iodine.  I  have  found  carbolic-acid  solutions  (1  :  20)  serviceable  in 
mild  cases. 

IxFLAMMATiox  OF  THE  Glaxd  Peoper  depends  in  the  vast  major- 
ity of  cases  on  an  extension  of  a  gonorrhoeal  inflammation  from  the 
vulva  through  the  duct.  In  proof  of  this  the  gonococcus  has  been 
found  in  the  secretions  from  diseased  glands.  Inflammation  may  also 
follow  the  introduction  of  other  irritating  vaginal  discharges,  such  as 
those  from  cancer,  and  also  from  traumatism.  As  a  result  of  the  inflam- 
matory swelling  of  the  mucous  membrane  the  duct  always  becomes 
closed.  The  inflammation  almost  invariably  ends  in  suppuration 
and  the  formation  of  an  abscess.  It  is  a  more  serious  affection  than 
the  one  already  described,  in  that  it  involves  more  tissue,  makes  a 
much  larger  tumor,  and  produces  more  constitutional  disturbance, 
with  fever. 

Undoubtedly,  many  of  the  cases  of  so-called  abscess  of  the  gland 
of  Bartholin  involve  only  the  duct.  If  the  abscess  goes  on  uninter- 
fered  with,  it  ends  with  rupture,  sometimes  through  several  openings. 
These  leave  fistulse,  communicating  with  a  common  cavity  and  opening 
on  the  surface  of  the  labium  majus.  Before  rupture  takes  place  the 
tumor  is  situated  deeply  in  the  lower  part  of  the  labium  majus.  It 
can  be  felt,  if  small,  by  placing  the  index  finger  within  the  introitus 
vaginae  and  the  thumb  outside  of  the  labium.  The  tumor  may  reach 
a  very  great  size,  with  extensive  inflammation  of  surrounding  parts, 
before  rupture  takes  place.  The  inguinal  glands  of  the  affected  side 
are  sometimes  enlarged  and  tender. 

Diagnosis. — The  position  of  the  tumor  will  serve  to  distinguish  it 
from  most  other  diseases.  The  aifections  with  which  it  might  be  con- 
founded are  pudendal  hernia,  hydrocele,  and  other  kinds  of  abscess. 
From  the  first  two,  the  history,  together  with  the  character  of  the 
tumor,  and  the  presence  of  inflammation  and  its  symptoms,  should 
distinguish  it.  The  different  abscesses  which  are  met  Avith  are  either 
traumatic  in  their  origin,  or  result  from  the  sujjpuration  of  a  pre-exist- 


I)/sj:asi:s  of  'riir:  skix  afff.ctisc  tiif  vflva.       501 

in«i|;  cyst  or  liii'iii;it(»iii;i.  In  all  (Iwsc  iii^taiiccs  the  historv  will  aid  in 
tlic  (liajiiiosis.  Alts'-csscs  arniiiid  tlic  rcrtiiin  may  also  closclv  simulate 
abscess  ot"  this  nland.  'riicsc  aiisccsscs  al\\a\s  rcsidt  iVoiii  fecial  dis- 
ease, such  as  ideei-ation,  lissure,  stricture,  or  hemorrhoids.  The  historv 
of"  such  |)re-existiu<;-  trouble,  together  with  the  result  of"  a  rectal  exam- 
ination, will  <;'euerally  throw  li;:.ht  on  the  ease.  I  have  seen  several 
siieh  abscesses  resulting-  from  stricture  ol"  the  rectum,  and  in  each  case 
there  was  a  labio-i-ectal  fistida. 

Treatment. — This  will  depend  on  the  stai^c  of  the  disease.  If  seen 
early  and  of  a  traumatic  nature,  leeches  may  be  a])])lied.  II"  of  a  .-jx- 
cific  character,  nothino-  can  be  done  to  abort  the  attack,  and  we  have 
only  to  await  su|)|)ni-ation,  which  can  be  ha.stcned  by  poultices.  As 
soon  as  the  j)rcscnce  of  pus  can  be  made  out,  a  free  incision  should  be 
made  on  the  inner  side  of  the  labium  majus.  The  cavity  nuist  then  be 
irrij>;ated  and  washed  out  with  the  silver-nitrate  solution,  and  packed 
with  iodoform  cotton.  This  may  be  repeated  several  times,  until  the 
cavity  fills  by  granulation.  If  a  recurrence  takes  place,  a  large  piece 
of  the  wall  of  the  abscess  should  be  cut  out,  and  the  cavity  painted  out 
with  some  strong  caustic,  such  as  nitric  acid.  It  is  sometimes  recom- 
mended to  extirpate  the  gland,  a  matter  of  no  great  difificulty.  An 
incision  should  be  made  over  the  gland,  the  whole  enucleated,  and 
the  fresh  surfliccs  brought  together  with  deep  sutures.  Free  incision 
and  caustics  will  suffice  in  almost  all  cases. 


Diseases  of  the  Skin  affecting  the  Vulva. 

Under  this  head  will  be  considered  those  diseases  affecting  the  vulva 
Avhich  are  commonly  included  among  the  diseases  of  the  skin. 

Alopecia. — The  hair  on  the  external  genitals  is  generally  lost  after 
each  labor;  but  the  loss  and  the  reproduction  are  so  gradual,  being  sim- 
ultaneous, that  the  fact  is  not  generally  noticed.  In  certain  diseases 
in  which  there  is  a  great  lowering  of  the  general  system,  the  wa.sting 
aifecting  particularly  the  genitals,  the  growth  of  the  hair  is  interfered 
with,  and  it  may  be  entirely  lost.  This  occurs  sometimes  in  cancer  of 
the  uterus,  especially  in  old  women.  Premature  and  senile  baldness, 
which  so  commonly  affects  the  scalp,  is  rarely  seen  affecting  the  pubic 
hair. 

Alopecia  areata,  the  nature  of  Avhich  is  not  well  understood,  though 
many  consider  it  as  parasitic,  sometimes  affects  the  whole  body  or 
certain  circumscribed  areas,  one  of  which  may  include  more  or  less 
of  the  external  genitals.  As  the  presence  or  absence  of  hair  on  the 
pubes  is  of  little  consequence,  no  treatment  directed  to  this  region  is 
necessary. 


502  DISEASES   OF  THE   VULVA. 

Inversion  of  the  Haie  of  the  Labia  (Trichiasis). — Meigs ^  has 
described  two  cases  where  strong  stiif  hairs,  found  on  the  edges  of  the 
labia,  were  turned  in,  as  they  sometimes  are  on  the  eyeHds.  This  condi- 
tion provoked  considerable  irritation  and  led  to  intense  pruritus.  Such 
conditions  are  rare,  and  would  be  apt  to  be  overlooked.  Removal  of 
the  oifending  hair  and  the  destruction  of  the  follicles  by  electrolysis 
would  be  the  only  and  a  most  effectual  treatment. 

Herpes  vulvaris  (iJ.  pudendalis). — This  affection  is  not  very 
common,  and  is  chiefly  met  with  in  young  women  and  among  the 
unchaste.  Greenough  considers  that  gonorrhoea  and  the  venereal  dis- 
eases are  predisposing  causes.  There  is  certainly  an  individual  pre- 
disposition without  assignable  cause,  which  shows  itself  by  repeated 
attacks.  The  parts  usually  affected  are  the  labia  majora,  and  occasion- 
ally the  nymphge  and  the  skin  around  the  vulva.  It  generally  causes 
very  little  pain  or  sensation  of  any  kind,  but  it  may  begin  with  burn- 
ing and  itching,  and  even  rarely  with  severe  neuralgic  pain.  There 
are  in  the  beginning  vesicles,  singly  or  in  groups,  on  a  slightly  red- 
dened base.  The  contents  of  the  vesicles  soon  become  turbid,  and 
crusts  form,  so  that  at  the  end  of  two  days  only  scales  or  scabs  can 
be  found.  There  may  be  one  or  more  groups  of  vesicles,  usually  not 
more  than  two  or  three,  rarely  ten  or  fifteen.  The  scales  or  crusts  may 
come  off  and  leave  a  slight  ulcer.  The  course  of  the  disease  is  usually 
about  a  week ;  but  often  one  crop  of  vesicles  is  succeeded  by  another, 
so  that  the  whole  course  of  the  affection  may  be  extended  over  a  num- 
ber of  weeks.  If  there  is  much  itching,  the  consequent  scratching  may 
result  in  excoriations,  or  even  large  deep  ulcers. 

Diagnosis. — Great  care  must  be  taken  not  to  confound  this  simple 
disease  with  true  venereal  ulcers.  The  diagnosis  can  usually  be  made 
by  watching  the  case,  and  observing  the  formation  of  new  lesions,  and 
the  rapid  and  complete  disappearance  of  the  old  under  simple  treat- 
ment. For  this  reason  all  caustics,  which  might  make  indurations,  are 
to  be  withheld,  and  simple  ointments  used,  which  will  not  obscure  the 
course  of  the  disease.  If  under  this  plan  of  treatment  the  ulceration 
grows  larger  and  suppuration  takes  the  place  of  the  watery  discharge, 
the  specific  nature  of  the  ulcer  will  be  manifest. 

Treatment. — It  is  advised  by  some  authorities  to  withhold  water  in 
any  form  as  an  application  to  the  affected  parts.  Ointments  of  borax, 
or  boric  acid,  or  oxide  of  zinc,  or  lead  may  be  used  with  benefit.  Duhr- 
ing  recommends  borated  cotton  as  a  dressing.  A  large  pad  can  be 
worn  and  kept  in  place  by  a  bandage.  Dusting  with  talc,  calomel, 
bismuth,  or  starch  may  prove  efficacious.  A  gouty  or  lithsemic  con- 
dition of  the  system  sometimes  accompanies  herpes,  and  perhaps  stands 

1  C.  D.  Meigs,  Am.  Jown.  of  Med.  Scl,  1862,  xliii.  328. 


DISEASES   OF  THE  SKl.X  AFFECTiyO    TlIF    VULVA.         OCJ^ 

ii)  the  rchitioM  ot"  caiix'  and  ctlfct.      Miilicatioii  (liiLftod  tu  its  rclicl'  is 
certainly  indit-atcd  if  it  is  found  to  exist. 

I'uiUKJo. —  This  alVcftion,  <ii'iu'rally  callfd  liciien  by  Jiritisli  writers, 
is  a  j)aj)idar  disease,  whicli  sometimes  attacks  the  jrenitals  in  connection 
with  its  aj)|)earance  on  other  parts  of  the  hody.  As  it  is  cliaracterized 
hy  i:;reat  itching-,  its  aj)]K'arance  is  apt  to  be  much  altered  by  the  fre- 
quent scratchinir;  jind  a  diaijnosis  can  best  be  made  by  examinintr 
other  parts  of  the  body  where  the  eru})tion  remains  unchanged,  as 
advisetl  by  ]Mr.  Tait. 

The  treatment  rec<)inni('ndcd  is  diy  ])owd('rintj  with  bismuth  and 
similar  sul)stances,  or  bathing  with  strong  solutions  of  carbolic  acid. 
Careful  attention  should  be  paid  to  the  patient's  general  health.  The 
disease  is  very  difficult  to  cure  and  runs  a  long  course. 

Erythema. — The  outside  of  the  labia  and  the  contiguous  parts  of 
the  thigh,  as  well  as  the  cleft  between  the  nates,  are  often  affected  by 
this  disease,  especially  in  hot  weather.  It  is  brought  on  by  exercise, 
want  of  cleanliness,  and  irritating  discharges,  and  is  sometimes  so  great 
an  annoyance  as  to  compel  almost  complete  abstention  from  walking. 
A  case  under  my  care  has  resisted  almost  every  treatment,  and  has 
experienced  really  severe  suffering.  It  is  commonly  met  with  in  fat 
people,  but  a  peculiarly  thin  and  sensitive  skin  seems  to  be  a  pre- 
requisite. The  affected  parts  become  red,  irritated,  and  even  raw. 
They  are  ver\'  sensitive,  and  the  movement  of  one  surface  on  another 
causes  considerable  pain. 

Treatment. — As,  in  these  cases,  there  is  generally  a  tendency  to  sub- 
oxidation,  the  condition  of  the  urine  should  be  carefully  examined,  and 
the  lithaemic  condition,  if  present,  removed  by  alkalies,  careful  diet,  and 
exercise.  Locally,  dr^'ing  powders  afford  much  relief.  Bismuth  and 
boric  acid,  one  part  to  ten,  and  powdered  talc,  are  among  the  best. 

Eczema  may  be  either  acute  or  chronic. 

Acute  Eczema. — The  manifestations  of  this  disease  on  the  vulva  do 
not  differ  much  from  those  on  other  parts  of  the  body  ;  it  is  a  compar- 
atively rare  affection.  Its  causes  are  obscure,  but  it  is  sometimes 
de])endent  on  uterine  or  ovarian  disease,  leucorrhceal  discharges,  and 
diabetes.  The  parts  attacked  may  be  the  labia  or  mons,  and  the 
process  may  even  extend  into  the  vagina.  The  labia  become  swollen 
and  red;  vesicles  appear,  which  soon  break  and  leave  a  raw  surface, 
from  which  a  thick,  gluey  fluid  is  freely  secreted.  This  discharge 
stiffens  on  the  clothing  when  dry,  and  forms  crusts  over  the  affected 
part.  Op])osing  surfaces  are  often  glued  together.  The  symptoms  are 
burning  and  itching,  sometimes  of  the  most  agonizing  character.     The 


504  DISEASES  OF  THE   VULVA. 

disease  may  begin  as  an  acute  affection ;  but,  if  not  removed  by  treat- 
ment, it  tends  to  become  chronic. 

Chronic  Eczema. — This  form  of  the  disease  may  be  subacute  from  the 
start,  or  may  result  from  an  acute  attack.  The  parts  usually  affected 
are  the  crease  between  the  labia  majora  and  minora  and  the  mons. 
We  find  a  red,  slightly  raised  surface ;  the  color  varying  from  light  to 
dark  red,  and  fading  imperceptibly  into  the  surrounding  skin.  The 
portion  attacked  may  be  quite  small,  or  extend  over  a  considerable  sur- 
face. Sometimes  the  skin  is  covered  with  scales ;  and  there  may  be 
deep  excoriations  and  small  crusts,  due  to  scratches.  The  surface  may 
exude  small  quantities  of  clear  watery  fluid.  The  symptoms  of  this 
form  do  not  differ  much  from  those  of  the  acute  disease.  There  is 
usually  a  burning  and  itching,  worse  at  different  parts  of  the  day,  and 
a  feeling  of  stiffness  in  the  parts.  The  disease  is  very  rebellious  to 
treatment,  and  when  cured  in  one  place  often  moves  to  another. 
Sometimes  it  responds  quickly  to  treatment,  and  recurs  again  with 
equal  promptitude. 

Treatment. — For  the  acute  form  the  black  wash  is  highly  recom- 
mended, together  with  oxide-of-zinc  or  calomel  ointment.  Carbolic- 
acid  ointment  (1  :  60)  is  also  of  value.  The  crusts,  if  formed,  must 
be  all  removed  by  poultices  and  the  parts  kept  perfectly  clean.  For 
this  purpose  water  should  not  be  used,  but  oil  or  vaseline  on  absorb- 
ent cotton  or  lint. 

In  the  chronic  form  great  relief  to  the  itching  may  be  derived  from 
the  application  of  very  hot  water  on  a  sponge,  followed  by  carbolic- 
acid  ointment.  I  recently  cured  a  most  persistent  case  with  borax  and 
glycerin.  The  tarry  preparations,  such  as  oil  of  cade  made  into  an 
ointment,  will  be  found  beneficial ;  and  painting  the  parts  with  very 
strona:  solutions  of  silvei*  nitrate  or  tincture  of  iodine  once  in  four  or 
five  days  does  good. 

Erysipelas. — When  confined  to  the  vulva  this  disease  does  not 
differ  from  the  same  affection  found  elsewhere  on  the  body.  It  is  not 
uncommon  in  children,  especially  infants,  and  is  said  to  be  common  in 
women  subject  to  discharges  from  the  vagina  of  an  irritating  character 
(Hildebrandt),  as  in  vesico-vaginal  fistula.  The  treatment  is  to  be  car- 
ried out  on  the  same  general  principles  as  when  other  parts  are  affected. 

Pityriasis  versicolor. — This  disease  is  due  to  the  gro^vth  of  a 
vegetable  parasite  {Microsporon  furfur).  It  is  characterized  by  irreg- 
ular spots  or  blotches,  of  a  yellowish  color,  slightly  raised  above  the 
surface.  Sometimes  the  spots  are  of  a  brownish,  dirty  color.  It  may 
be  distributed  over  large  areas  or  confined  to  the  mons  and  vulva, 
extendino-  more  or  less  on  to  the  abdomen  and  thighs.     It  often  causes 


disi:asi-:s  of  the  sk/x  affkctisc  tiif  vii.va.       505 

^rciit  anxiety,  as  do  most  diseases  on  the  skin  of  tlie  vulva,  on  aeeonnt 
of  a  suspicion  ot"  its  speeilie  nature,  and  is  n(»t  uiil"re(|uently  mistaken 
for  sonietliing  of  tliis  kind.  If  there  is  any  douht,  a  niieroscoj)ic 
examination  of  the  serapings  from  affected  spot.s  will  set  it  at  rest. 
Trcdf incut. — This  consists  simply  in  the  ap])lication  of  a  jiarasitieide. 
For  this  purpose  corrosive  sublimate  will  he  found  efficient  in  solution 
of  2  to  o  grains  to  the  ounce.  Solutions  of  hyposulphite  of  soda,  car- 
bolic acid,  and  tincture  of  iodine  will  also  answci-.  Fi-e(pient  washinjrs 
with  stron»5  soap  will  render  the  action  of  the  a])j)lications  more  certain. 
Great  attention  to  cleanliness  is  necessary  in  all  cases. 

Scabies, — This  affection  seldom  occurs  on  the  genitals,  but  the  pos- 
sibility of  such  an  event  must  not  be  forgotten,  as  an  accurate  diagnosis 
is  essential  to  success  in  treatment.  A  careful  examination  of  the  hands 
will  serve  to  make  the  diagnosis  complete.  The  usual  sulphur  treatment 
is  quite  applicable.  As  it  may  complicate  other  forms  of  skin  disease, 
or  even  cause  them,  the  possibility  of  its  occurrence  should  always  be 
borne  in  mind. 

Pediculus  pubis. — The  crab-louse  is  a  not  infrequent  inhabitant 
of  the  mons  and  adjacent  parts.  In  the  earlier  stages  of  its  occupancy 
the  only  symptom  is  itching,  so  that  the  presence  of  this  symptom, 
without  other  good  reason,  should  always  lead  to  an  examination,  when 
the  presence  of  the  intruder  can  be  made  out.  The  cause  is  almost 
always  direct  transference  from  body  to  body,  usually  at  the  time  of 
sexual  intercourse.  Cases  have  been  reported  where  the  method  of 
transference  was  inexplicable.  The  amount  of  local  disturbance  varies 
with  the  individual  and  the  length  of  time  the  parasites  have  been 
present.  When  an  eruption  exists  it  usually  resembles  an  eczema. 
The  animal  is  to  be  found  closely  adherent  to  the  roots  of  the  hairs. 
The  excrement  and  ova  can  also  occasionally  be  seen. 

Treatment. — The  object  is  to  destroy  the  parasite.  This  can  be  done 
with  a  mercurial  ointment  or  wath  some  liquid  preparation.  Tincture 
of  del]ihinium  has  long  and  justly  enjoyed  a  great  rc])utation.  A  solu- 
tion t)f  carbolic  acid  (5  per  cent.)  and  corrosive  sublimate  (1  :  1000)  will 
also  act  efficiently.  It  has  been  recommended  (Tait)  to  begin  the  treat- 
ment of  most  of  the  eruptions  around  the  vulva  with  carbolic-acid 
lotion,  in  order  to  remove  the  possibility  of  this  complication — a  sug- 
gestion which  can  be  well  carried  out,  especially  in  the  lower  walks  of 
life  and  in  dispensary  practice. 

Pruritus  vuly^. — A  large  number  of  the  eruptive  and  inflam- 
matory diseases  of  the  vulva  are  attended  with  more  or  less  marked 
itching  and  burning.     In  the  disease  under  consideration  this  symp- 


506  DISEASES  OF  THE   VULVA. 

torn  exists,  but  without  apparent  anatomical  lesion,  at  the  seat  of  the 
itching,  as  its  cause. 

Cause. — There  are  several  varieties  of  the  aifection,  dependent  on 
the  cause.  Unquestionably,  one  of  the  most  common  forms  is  that 
due  to  an  irritating  discharge.  The  discharge  may  be  either  urine,  or 
abnormal  vaginal,  uterine,  or  urethral  secretions.  So  commonly  is  this 
symptom  found  in  diabetes  that  an  otherwise  unexplained  pruritus 
should  always  lead  to  an  examination  of  the  urine  for  sugar.  The 
vaginal  discharge  may  be  profuse  and  noticeable,  attracting  the  patient's 
attention  at  once,  or  it  may  be  so  small  in  amount  as  to  have  entirely 
escaped  notice.  The  discharge  may  have  its  origin  either  in  vaginitis, 
endometritis,  cancer,  or  other  growth.  Before  the  menopause  attacks 
of  leucorrhoea  of  uterine  origin,  attended  by  pruritus,  are  not  uncom- 
mon, and  are  generally  transient,  being  easily  relieved  by  treatment 
or  soon  passing  ofP  if  left  alone.  After  the  menopause  these  transient 
attacks  are  more  seldom  met  with,  and  the  condition,  once  established, 
is  apt  to  remain  indefinitely  as  senile  catarrh.  These  cases  aiFord  the 
most  rebellious  examples  of  pruritus.  It  must  not  be  supposed  that 
endometritis  and  vaginitis  alone  can  be  the  source  of  the  irritating  dis- 
charge. It  may  come  from  the  urethra  as  the  result  of  a  urethritis, 
from  Skene's  glands  in  the  urethra,  from  the  vulvo-vaginal  glands,  or 
even  from  the  mucous  follicles.  These  facts  must  not  be  overlooked 
in  searching  for  the  cause. 

Another  form  of  the  trouble  is  that  due  to  purely  neurotic  influences. 
These  cases  are  met  with  most  commonly  during  pregnancy,  and  the 
itching  sometimes  extends  from  the  vulva  over  the  abdominal  walls,  so 
as  to  involve  nearly  the  whole  body.  It  has  been  thought  to  explain 
these  cases,  by  supposing  that  the  irritation  is  spread  by  direct  inocula- 
tion with  secretions  from  the  finger-nails  of  the  patient.  This,  how- 
ever, will  not  explain  all  the  cases,  nor  is  this  supposition  necessary,  as 
dermatologists  admit  a  pruritus  of  neurotic  origin. 

Still  a  third  class  is  described,  where  the  itching  is  attributed  to  the 
presence  of  parasites.  These  may  be  the  ordinary  pin-worms  which 
so  commonly  affect  the  rectum.  They  have  been  asserted  to  act  in 
two  ways — either  by  reflex  action  or  by  direct  contact  through  migra- 
tion into  the  vagina.  The  latter  mode  may  occasionally  occur  in  very 
young  children,  but  the  writer  has  never  seen  anything  of  the  kind  in 
adults,  and  doubts  its  possibility.  If  the  worms  do  get  into  the  vagina, 
the  only  way  they  could  act  on  the  vulva  would  be  by  means  of  a  dis- 
charge, induced  by  their  presence  in  the  vagina.  Vegetable  parasites 
have  been  asserted  to  grow  in  the  secretions  and  to  be  the  cause  of  the 
pruritus.  The  Leptothrix  vaginalis  and  Oldium  albicans  are  the  varie- 
ties described,  the  latter  being  considered  the  most  important  in  its 
eifects. 


vjsi:asj:s  of  the  skis  AriKcnsa  Tin:  vriVA.       007 

It  must  n(»t  1)0  f()r<i(»tt('ii  t!i:it  many  of"  the  diseases  <»!'  the  vulva 
alreatlv  (lesei'ihed  have  as  a  prdiiiiiieiil  >\iii|)t(iiii  weli-mai'ked  |)niritiis. 

Si/iiijitoiiiK. —  The  |)riiii:ir\'  >\  iiipldiii  i-  an  itrliin^  on  the  -iirliicc  ut' 
the  vulva.  It  may  lie  ei>nliiied  to  a  limited  area  oi'  e.\teu<l  oNcr  all 
the  external  <>i'«:aiis.  A  common  seat  is  hetweeii  the  labia  minoi'a 
and  majora,  also  nu  the  inner  surliiees  of  the  laliia  majoi-n.  The  jirri- 
neum  may  he  a  Heeled,  and  the  itehinj;'  extend  to  the  j)arts  ai'onnd  the 
amis.  The  .siMisation  is  ol"ten  desei'ihed  as  an  itehinu'  or  hurnin^'-,  w  ith 
an  almo-t  nneontrollalilc  desire  to  scratch  and  tear  the  pai'ts  I'or  the 
|)nri)(»se  ot"  *iainint;-  reliei".  The  trouble  is  not  <i'enerally  constant, 
thouii'h  in  some  ea.ses  it  is  so.  It  is  more  commonly  intermittent,  the 
remissions  varying  from  hours  to  days  or  weeks.  In  some  cases  it 
eomes  on  at  niuht  after  iictting  into  bed.  This  is  ])articidar]y  true  of 
the  neurotic  form.  In  other  eases  it  is  worse  in  the  early  morning  or 
some  particular  part  of  the  day.  Again,  it  will  only  be  i'elt  when  the 
menstrual  jieriod  is  approaching  or  just  after  its  close.  After  the  dis- 
ease has  lasted  for  some  time  the  parts  either  become  thickened  and 
leathery  from  constant  rubbing,  or  they  become  covered  with  fun-ows 
and  ulcerati(His  from  the  use  of  the  finger-nails.  These  furrows,  being 
raw  or  covered  with  crusts,  greatly  resemble  an  eruption.  In  fact,  an 
eczema  may  be  thus  induced  and  complicate  the  original   malady. 

Treatment. — The  first  step,  in  the  institution  of  a  rational  treatment, 
is  to  find  the  cause  and  nature  of  the  disease.  If  it  be  parasitic  in  its 
origin,  the  parasites  must  be  removed.  For  ])in-worms  nothing  is  bet- 
ter than  quassia  infusion.  The  treatment  must  be  directed  both  to  the 
vagina  and  the  rectum,  the  original  source  of  the  worms.  For  the  veg- 
etable parasites  solutions  of  carbolic  acid  or  sulphate  of  zinc  will  .-uffice. 
If  the  symptom  is  due  to  any  of  the  eruptions,  or  local  inflammatory 
affections  found  on  the  vulva,  treatment  for  these  particular  conditions 
must  be  employed.  If  none  of  these  conditions  exist,  a  careful  search 
nnist  be  made  for  an  irritating  discharge.  This  may  be  so  evident  as 
to  attract  the  patient's  attention  and  be  by  her  recognized  as  the  cause ; 
but,  again,  it  may  be  so  slight  as  to  escape  entirely  her  observation  as 
well  as  that  of  a  careless  investigator.  In  order  to  determine  the 
causative  relation  of  a  suspected  vaginal  or  uterine  discharge,  we  may 
first  carefully  clean  out  the  vagina  by  an  injection  of  hot  water  and 
borax,  and  then  lightly  pack  the  vagina  with  dry  salicylated  or  boratcd 
abs(,)rbent  cotton.  This  will  hold  back  the  discharge,  and  in  proportion 
to  the  relief  afforded  by  the  packing  will  the  causative  influence  of  the 
discharge  be  known.  Having  once  determined  the  influence  of  the  dis- 
charge, proper  means  may  be  taken  to  relieve  it  by  aj)propriate  treat- 
ment, directed  to  the  vagina,  cervix,  endometrium,  etc.  In  my  hands 
the  plan  of  ]iacking  with  dry  cotton  or  simply  placing  a  large  A\"ad  of 
drv  absorbent  cotton  within  the  mouth  of  the  vau'ina — somethini::  which 


508  DISEASES  OF  THE  VULVA. 

the  patient  soon  learns  to  do  for  herself — has  often  served  to  afford 
immediate  relief,  while  treatment  was  being  directed  to  the  removal  of 
the  cause. 

For  the  alleviation  of  the  symptoms  many  things  have  been  recom- 
mended. Very  hot  water,  applied  directly  to  the  parts  with  a  large 
sponge,  often  aifords  great  relief.  The  water  may  be  medicated  with 
borax,  boric  acid,  soda,  tobacco  (|ss-Oj),  lead,  carbolic  acid  (.5j-§iv), 
zinc  sulpho-carbolate  (3ij-5iv),  tincture  of  opium,  etc.  The  following 
are  a  few  formulae  which  have  been  found  useful,  and  are  taken  mostly 
from  Goodell : 

I^.  Acidi  acetici,  f|j  ; 

Glycerini,  f^iij- 

M.  et  Sig.     Apply  locally. 

^.  Acidi  carbolici,  gr.  xij  ; 

Morphinae  acetatis,        gr.  viij  ; 

Acidi  hydrocyan.  dil.   f^ij  ; 

Glycerini,  f  §j  ; 

Aquam,  ad  f^iv. 

M.  et  Sig.     Apply  locally. 

^.  Chloralis, 

Camphorse,  da  §ss. 

Misce,  et  adde — 

Unguenti,  |j ; 

Acidi  borici,  .5ss. 

M.  et  Sig.     Apply  with  a  brush. 

!^.  Potassii  cyanidi,  gi'-j~iyj 

Liq.  calcis,       '  fgiv ; 

Adipis,  Siv. 

M.  et  Sig.     Apply  locally. 

Many  similar  formulse  Avill  be  found  scattered  through  the  textbooks, 
but  these  have  proved  more  or  less  useful  in  the  writer's  hands,  and 
can  therefore  be  recommended. 

In  the  purely  neurotic  form,  remedies  directed  to  the  general  nervous 
system,  as  well  as  local  sedatives,  may  be  of  benefit.  Among  those 
most  likely  to  do  good  are  the  bromides  and  zinc. 

In  diabetes  cleanliness  is  of  the  utmost  importance,  and  every  drop 
of  urine  should  be  washed  away  from  the  vulva  as  soon  as  it  is  passed. 
Thomas  advises,  in  order  to  keep  it  from  touching  the  parts,  the  regular 
use  of  the  catheter.  In  pregnancy  the  condition  of  the  cervix  and  vagina 
must  be  carefully  investigated,  and  local  treatment  used  if  necessary, 
as  has  been  found  quite  safe.  In  the  gouty  diathesis  which  will  not 
uncommonly  be  found  complicating  these  cases,  especially  where  there 


SERPfdiyors  vasci-laj:  DrjiKyKiiArioy.  509 

is  an  tH'Zcnia,  tlic  iitiiiost  care  iniist  l)c  taken  witli  the  diet.  All  sweets, 
pastry,  and  i-icli  and  nndit;('stil)Ie  t'ttdd  nnist  Ix-  av<tide<l,  and  the  patient 
ur«;etl  to  taUe  plenty  ol"  exercise  ont  of"  dooi's.  A  re.-oit  to  the  alkaline 
mineral  watiTs  and  hot  snlphnr  haths  will  oiten  do  <;(»od.  It  is  not  to 
he  (orootten  that  the  p>nty  diathesis  is  j)artienlarlv  eoninion  in  this 
eoinitry  anion«i-  women,  and  is  es|)ecially  apt  to  show  itself  ai)()iit  the 
time  of  the  menopanse.  As  a  local  a|»plication  eocaino,  cither  as  an 
uintnient  with  huiolin  or  vaseline,  or  sprayed  on  in  watery  solntion, 
sometimes  affords  relief.  The  solution  must  be  strong,  and  even  then 
the  effeet  soon  passes  off.     Its  use  in  my  hands  has  been  unsatisfaetory. 

Serpiginous  Vascular  Degeneration. 

This  is  an  affection  described  by  Mr.  Lawson  Tait,'  which  consists 
of  a  progressive  atroj)hy  of  the  mucous  membrane  covering  the  inner 
surfaces  of  the  nymplue.  It  occurs  only  at  or  after  the  climacteric, 
and  is  a  very  distressing  and  intractable  complaint.  The  symptoms 
are  dyspareunia,  or  total  suspension  of  marital  intercourse,  from  the 
intense  ]>ain  produced  by  the  act ;  also  a  slight  yellowish  discharge 
and  scalding  on  passing  water.  Inspection  will  show  one  or  tAvo  spots 
of  redness  on  the  mucous  surface  of  the  nymphae,  varying  in  cohjr 
from  a  pale  brick-red  to  a  bright  ]>ur]ile.  The  spots  are  exquisitely 
sensitive  to  pressure.  If  watched  for  a  long  time,  these  spots  will  be 
seen  to  disappear  from  one  ])lace  and  to  appear  in  another,  or  the  dis- 
ease extends  serpiginously,  disappearing  from  the  old  site  as  it  pro- 
gresses toward  the  new.  The  course  is  very  slow,  lasting  for  years, 
for  it  seldom  stops  until  it  has  passed  over  the  Avhole  mucous  surface 
of  the  nymphfe.  During  its  progress  the  vestibule  slowly  contracts 
until  the  introitus  vaginae  is  so  small  as  scarcely  to  admit  a  finger. 

Microscopically,  Mr.  Tait  has  found  that  all  the  textures  are  re- 
moved, except  a  few  fibres  of  connective  tissue ;  the  walls  of  the  caj)il- 
laries  are  left  thin  and  dilated,  while  the  nerve-filaments  are  almost 
unprotected,  thus  explaining  the  chief  clinical  features  of  pain,  vascu- 
larity, and  later  contraction.  Finally,  the  nerves  and  vessels  disajijiear 
and  the  pain  and  redness  subside,  leaving  only  a  cicatricial  contraction. 

The  prognosis  is  good  as  to  ultimate  relief  from  suffering,  but  the 
chronic  course  of  the  disease,  extending  over  years,  and  the  residting 
contraction,  should  be  explained  to  the  patient. 

The  treatment  advised  is  to  touch  the  parts  with  strong  carbolic 
acid.  This  gives  temporary  relief.  Applications  of  a  plug  of  cotton 
soaked  in  a  saturated  solntion  of  neutral  acetate  of  lead  in  glycerin, 
placed  betAveen  the  nymphae  at  bedtime,  is  also  useful.  A  pledget  of 
dry  cotton  inserted  between  the  affected  parts  is  also  advised  to  give 

^  Diseases  of  Women,  p.  43,  1877. 


510  DISEASES  OF  THE   VULVA. 

relief  in  walking.     Any  existing  uterine  or  vaginal  disease  producing 
an  irritating  discharge  should  receive  attention. 

I  have  never  met  with  any  cases  of  this  disease,  and  am  unacquainted 
with  any  references  to  it  in  American  medical  literature.  Mr.  Tait 
thinks  it  is  often  overlooked,  and  that  many  cases  of  so-called  vagi- 
nismus are  due  to  its  presence. 


Hyperesthesia  of  the  Vulva. 

This  condition  of  the  vulva  was  first  described  by  Thomas,^  and  cer- 
tainly deserves  general  recognition.  In  describing  it  I  shall  follow 
closely  the  excellent  account  given  by  Dr.  Thomas. 

It  consists  of  an  excessive  sensibility  of  the  nerves  supplying  the 
mucous  membrane  of  some  portion  of  the  vulva.  The  area  of  tender- 
ness may  be  confined  to  the  vestibule,  to  one  labium  majus,  or  to  the 
meatus  urinarius.  The  whole  surface  of  the  vulva  except  the  outside 
of  the  labia  majora  may  be  affected,  as  the  writer  has  once  seen.  The 
disease  is  fortunately  not  very  frequent,  though  in  this  country  it  is 
certainly  much  more  common  than  the  disease  described  by  Mr.  Tait 
(see  previous  page).  It  seems  not  to  be  a  true  neuralgia,  but  an  abnor- 
mal sensitiveness  in  the  sensory  nerves  supplying  the  parts.  There  is 
no  inflammation,  but  perhaps  a  few  spots  of  erythematous  redness  here 
and  there. 

Cause. — It  occurs  most  commonly  at  or  about  the  menopause,  and  is 
predisposed  by  hysterical  and  hypochondriacal  states.  As  exciting 
causes  chronic  vulvitis  and  irritable  urethral  tumors  may  exist,  but 
in  other  cases  no  cause  whatever  is  to  be  found. 

Symptoms. — The  principal  symptom  is  pain  on  sexual  intercourse. 
Any  friction,  even  a  cold  or  unexpected  current  of  air,  produces  dis- 
comfort, while  pressure  is  absolutely  intolerable.  Walking  becomes 
difficult  and  the  general  health  suifers.  The  mind  is  disproportion- 
ately disturbed  and  depressed.  "  In  some  cases  it  seems  to  absorb  all 
the  thoughts,  and  to  produce  a  state  bordering  upon  monomania." 

Diagnosis. — It  must  be  distinguished  from  the  serpiginous  degenera- 
tion of  Tait,  Avhich  it  closely  resembles,  except  in  pathology  and  ulti- 
mate result;  also  from  vaginismus  and  irritable  urethral  tiunor. 
Neuroma  may  also  produce  similar  symptoms. 

Treatment — The  treatment  is  in  the  main  unsatisfactor5^  Thomas 
declares  that  he  has  not  succeeded  in  relieving  a  single  case.  In  one 
case,  which  I  had  the  opportunity  of  seeing  with  Dr.  Thomas,  he 
dissected  off  nearly  all  the  mucous  membrane  from  the  vulva,  with 
only  temporary  relief  Sims  has  done  the  same  operation  without  suc- 
cess.    Thomas  recommends  change  of  scene  and  surroundings,  separa- 

^  Diseases  of  Women,  p.  145,  1880. 


s^As^f  or  riii:  mi'sclks  of  the  pklvic  ii.ooii.       -^w 

tion  IVoiii  the  IiiisIkiikI,  witli  the  use  <if  all  agents  to  rotttcc  the  ^(•iici-al 
health;  all  local  pelvic  disease  is  to  he  cured,  and  tiic  ailected  j)arts  to  he 
iVe(|iieiitly  hatlied  with  warm  water  and  sedative  siihstaiu'cs  applied  in 
the  I'orni  of  ointments.  Amonii'  such  suhstanees  niav  he  mentioned  car- 
holii'  aeid,  cocaine,  chloi-oloini,  iudoiunn,  bismuth,  and  evanitle  of 
potassium. 


Spasm  op  the  Muscles  of  the  Pelvic  Floor. 

Any  or  all  of  the  muscles  <i-oin<r  to  make  up  the  pelvic  floor  may 
become  spasmodically  contracted.  These  spasms  are  manifested  most 
eommonly  diu'ing  coitus,  or  during  an  attempt  at  it,  but  in  some  of  the 
nuiscles — the  sphincter  ani,  for  example — the  spasm  occurs  at  other 
times.  To  a  spasm  affecting  particularly  the  constrictor  vaginae  nuis- 
cles we  give  the  name  of  "  vaginismus ;"  when  the  deeper  muscles, 
especially  the  levator  ani,  are  affected,  the  name  of  vaginismus  superior 
has  been  applied.  As  these  affections  seem  to  be  different,  though 
closely  related,  they  Mill  be  described  under  different  heads- 

YAGixiSirrs. — The  name  "  vaginismus "  was  first  given  by  Sims 
(1861)  to  a  spasm  of  the  constrictor  vaginae  muscles,  manifested  par- 
ticularly on  an  attempt  at  intercourse.  Huguier  (1834)  was  perhaps 
the  first  to  describe  spasmodic  contraction  of  these  muscles.  Kiwisch 
called  it  spasmus  vaginae,  while  Simpson  described  (1859)  the  same 
thing  under  the  name  of  vaginodvnia.  The  exact  definition  o-iven  bv 
Sims  is,  "  an  excessive  hyperaesthesia  of  the  hymen  and  vulvar  outlet, 
associated  with  such  involuntar}-  spasmodic  contraction  of  the  sphincter 
vaginae  muscle  as  to  prevent  coition." 

Cause. — About  fcM' diseases  of  women  has  there  been  more  differences 
of  opinion  than  about  this.  It  is  now  quite  evident  that  there  are  sev- 
eral classes  of  cases,  differing  in  their  nature  and  cause.  In  one  class 
the  cause  is  to  be  found  in  some  pathological  lesion  in  or  about  the 
vulvar  outlet ;  in  another  class  the  seat  of  the  irritation  causing  the 
reflex  spasm  of  the  muscle  is  found  to  be  in  distant  organs,  as  in  the 
uterus,  ovaries,  or  rectum ;  while  in  a  third  class  no  lesion  can  be  found, 
but  we  must  look  for  the  cause  solely  in  the  nervous  system. 

In  the  first  class  undoubtedly  the  lesion,  found  usually  in  the  hymen, 
is  most  commonly  induced  by  repeated  and  unsuccessful  attempts  at 
coitus.  The  cause  of  the  fiiilure  may  be  the  awkwardness  of  the  hus- 
band, through  which  he  presses  the  penis  in  the  wrong  direction ;  but  it 
may  be,  and  most  commonly  is,  found  in  some  partial  obstacle  on  the 
part,  of  the  woman.  This  may  be  a  rigid  and  resisting  hymen,  an 
unusually  small  vulvar  orifice,  or  a  relative  disproportion  between  the 
male  and  female  organs.    Again,  the  difficulty  may  be  found,  as  Schroe- 


512  DISEASES  OF  THE   VULVA. 

der  has  pointed  out,  iu  the  fact  that  the  vulva  is  placed  too  high  on  the 
pubes,  so  that  the  space  between  the  under  edge  of  the  symphysis  pubis 
and  the  fourchette  is  so  narrow  that  there  is  hardly  room  for  the  male 
member.  In  this  case  the  penis  either  presses  into  the  fossa  navicularis, 
or  more  commonly  impinges  on  the  parts  around  the  meatus  and  presses 
them  against  the  bone,  and  may  even  dilate  the  urethra  so  as  to  admit 
of  entrance  there.  Whatever  the  hinderance,  the  frequent  unsuccessful 
attempts  at  intercourse,  long  continued  and  forcible,  gradually  induce  a 
sensitiveness  and  soreness  of  the  parts,  sometimes  accompanied  by 
excoriations,  as  the  writer  has  several  times  seen — sometimes  by  sim- 
ple hyper£esthetic  spots,  so  that  the  woman  suffers  extremely  at  each 
attempt.  Following  a  law  which  exists  in  other  parts  of  the  body, 
the  muscles  surrounding  the  aifected  tender  parts  take  on  a  con- 
dition of  reflex  spasm,  and  the  condition  of  vaginismus  is  fully 
established. 

In  the  second  class  we  put  cases  dependent  on  what  might  be  called 
accidental  and  concomitant  lesions.  These  are  uterine  disease,  such  as 
displacements,  endometritis,  and  lacerated  cervix ;  a  prolapsed  and  tender 
ovary ;  vaginitis ;  disease  of  the  rectum,  as  piles,  fissure  and  pin-worms ; 
other  diseases  of  the  vulva,  as  fissure,  herpes,  eczema,  and  \'nlvitis. 
These  cases  are  distinguished  from  those  of  the  first  class  by  the  fact 
that  the  disease  does  not  come  on  at  the  beginning  of  married  life,  but 
later,  after  the  sexual  act  has  been  many  times  successfully  accom- 
plished, and  even  after  children  have  been  born. 

In  still  another  class  we  must  look  for  the  cause  more  in  the  nat- 
ural disposition  of  the  individual.  A  timid,  nervous  young  woman 
who  bears  pain  badly — and  in  this  respect  women  differ  markedly — is 
greatly  agitated  and  very  apprehensive  at  the  approach  of  her  husband. 
An  instinctive  dread  causes  her  to  offer  more  or  less  resistance,  which 
hinders  the  proper  accomplishment  of  the  sexual  act.  The  husband's 
efforts,  perhaps  forcible  and  rough,  are  attended  by  more  or  less  pain, 
and  this  magnifies  her  dread  and  in  turn  increases  her  resistance.  The 
muscles  of  the  thighs  and  abdomen — in  fact,  the  whole  muscular  system 
— are  thrown  into  a  state  of  tension  almost  amounting  to  spasm.  In 
the  case  of  the  muscles  around  the  vulvar  outlet  this  contraction  is 
heightened  by  the  actual  contact  of  the  penis,  and  a  condition  of  spasm 
is  finally  induced,  as  bad  as  in  any  of  the  other  cases.  Thus  we  have  a 
vaginismus  in  which  there  is  no  pathological  lesion,  and  yet  the  slight- 
est touch  of  the  vaginal  outlet  is  sufficient  to  call  into  being  all  the  cha- 
racteristic symptoms.  The  cause  is  evidently  largely  mental,  a  fear  of 
an  anticipated  pain  being  all  there  is  in  the  beginning.  Unquestion- 
ably, hysteria  mav  plav  a  large  part  in  the  causation,  and  is  always  to 
be  taken  into  account. 
■    In  the  experience  of  most  authors,  as  well  as  in  that  of  the  writer, 


m'ASM  or  rill-:  Mrs<ij:s  nr  riii:  i-i:iaic  i-i.non.       013 

the  most  coiniiioii  cases,  as  well  as  tlu-  severest,  are  those  oi'  the  first 
chiss,  the  h'sioii  heiiii:-,  as  Sims  pointed  out,  a  tender,  hypenestlietie 
coMintion  of  the  liynieii  oi'  [Kirls  iiinin'diatcK'  ai'miiid  it,  aec(iiii|i:ini('d 
by  more  oi'   h'ss  (•on^('stioll   and   <trten   eroded   and    reddened   spftts. 

Si/iiij)lniiis. — The  |n-inei|)al  symptoms  are  excessive  pain  and  spasm 
oi"  till-  muscles  ai'oimd  the  vid\a,  in(hiccd  1)\-  attempt-<  a(  >c\iial  inter- 
course. So  severe  docs  thi'  pain  ix'eomc  that  the  patient  '^-cts  to  reallv 
dread  the  approach  of  lier  hnshand,  and  all  attempts  are  linallv  uiven 
up.  II"  a  vatiinal  examination  is  made  in  i»ad  cases,  so  great  is  the 
j)ain  and  nervous  apprehension  that  the  patient  is  tlirowu  into  a  state 
of  violent  nervous  conuuotiou.  ( )ften  tliere  will  he  u;encral  nuiscular 
agitation,  intermittent  rigors,  and  a  most  dcplnral)le  state  aniountinir  to 
even  terror  and  agony  (Sims).  If  now  the  finger  is  pressed  into  the 
vagina,  the  muscles  will  generally  be  found  to  Ix'  in  a  state  of  violent 
contraction.  This  spasm  may  be  shared  by  all  the  nniscles  of  the 
pelvic  floor,  especially  the  sphincters.  In  some  cases  the  spasm  and 
pain  are  not  so  severe,  amounting  rather  to  a  hinderance  than  an  abso- 
lute prevention  to  connection.  Other  causes  have  been  noted  for  the 
spasm.  Thomas  mentions  a  case  where  there  was  a  tendencv  to 
spasm  "  upon  sudden  changes  of  position  or  washing  the  genitals." 
In  another  case  the  spasm  was  brought  on  by  contact  of  the  clothing 
or  finger  used  to  stop  a  pruritus  vulvae.  AValking  has  also  pnjved 
sufficient  to  bring  on  an  attack.  Barnes  observed  cases  where  attemj)ts 
at  connection  were  followed  by  convulsions  and  syncope. 

Diar/nosis. — The  history  of  the  case  will  be  generally  sufficient  to 
determine  the  nature  of  the  affection  complained  of.  A  careful  dis- 
tinction must  be  made  between  vaginismus  and  dyspareunia  dependent 
on  other  causes  and  unassociated  with  spasm.  If  there  is  any  doubt,  a 
vaginal  examination  will  generally  bring  on  a  spasm  accompanied  by 
severe  pain.  In  some  cases  even  the  touch  of  a  camel's-hair  pencil 
will  be  enough  to  provoke  the  characteristic  symptoms.  On  the  other 
hand,  the  writer  has  seen  cases  where  a  vaginal  examination,  even  with 
a  speculum,  Avas  possible  without  bringing  on  a  spasm,  and  yet  the 
slightest  atteiupt  at  intercourse  caused  the  introitus  vaginne  to  shut  up 
as  if  held  by  a  clamp.  In  another  case  the  patient  could  introduce 
herself  the  largest-sized  Sims  dilator,  but  coitus  was  impossible.  Both 
these  were  nervous  eases,  and  one  of  them  had  borne  a  child,  impreg- 
nation having  followed  a  single  successful  coitus. 

P/-or/>(o.s/.s. — If  a  local  cause  can  be  found  for  the  disease,  the 
chances  of  a  perfect  cure  are  good  ;  but  when  the  disease  seems  tt)  be 
dependent  on  a  purely  nervous  condition,  it  is  extremely  difficult  to 
cure.  If  left  to  itself  without  treatment,  the  disease  Avill  continue 
indefinitely.  Jenks  rejiorts  a  ease  of  thirty  years'  standing.  It  is 
often  supposed  that  ehildl)earing  will  certainly  cure  the  disease ;  this, 
Vol..  i.—:vA 


514  DISEASES  OF  THE   VULVA. 

however,  is  a  mistake,  especially  in  the  nervous  cases,  as  the  writer  has 
several  times  witnessed. 

Treatment — The  treatment  proposed  by  Sims,  originated  after  much 
research  and  many  trials,  was  based  on  his  idea  of  the  pathology,  and  is 
the  best  yet  devised  for  the  cases  which  I  have  described  as  belonging 
to  the  first  class.  His  plan  consists  in  first  dissecting  away  with  curved 
scissors  the  whole  of  the  hymen.  This  leaves  a  raw  surface  which  heals 
by  granulation.  In  order  to  prevent  this,  as  well  as  to  immediately 
control  hemorrhage,  I  have  brought  the  cut  edges  of  the  mucous  mem- 
brane together  with  a  continuous  suture  of  fine  catgut,  thus  avoiding 
the  production  of  a  cicatrix.  After  the  wound  has  healed,  the  next 
step  is  to  enlarge  the  opening  of  the  vagina,  thus  cutting  the  tense 
and  tender  cicatrix  if  there  be  one.  Sims's  plan  is  as  follows  :  "  Place 
the  patient  on  her  back,  as  for  lithotomy ;  pass  the  index  and  middle 
fingers  of  the  left  hand  into  the  vagina ;  separate  them  laterally,  so  as 
to  dilate  the  vagina  as  widely  as  possible,  putting  the  fourchette  on  the 
stretch  ;  then  with  a  common  scalpel  make  a  deep  cut  through  the  vagi- 
nal tissue  on  one  side  of  the  mesial  line,  bringing  it  from  above  down- 
ward and  terminating  at  the  raphe  of  the  perineum.  This  cut  forms 
one  side  of  a  Y.  Then  pass  the  knife  again  into  the  vagina,  still  dilat- 
ing with  the  fingers  as  before,  and  cut  in  like  manner  on  the  opposite 
side  from  above  downward,  uniting  the  two  incisions  at  or  near  the 
raph6,  and  prolonging  them  quite  to  the  perineal  integument.  Each 
cut  will  be  about  two  inches  long — i.  e.  half  an  inch  or  more  above  the 
edge  of  the  sphincter,  half  an  inch  over  its  fibres,  and  an  inch  from  its 
lower  edge  to  the  perineal  raphe." 

The  further  treatment  consists  in  the  wearing  of  a  glass  dilator  de- 
vised by  Sims  and  known  by  his  name.  This  must  be  introduced  and 
worn  daily  for  several  weeks,  or  till  the  parts  are  entirely  healed  and  all 
sensitiveness  removed. 

In  the  nervous  cases,  if  there  is  no  lesion  discoverable,  the  forcible 
dilatation  of  the  parts  under  ether — and  for  this  purpose  I  have  found 
Goodell's  speculum  a  most  excellent  instrument — followed  by  the  glass 
dilators,  gradually  increasing  the  size  until  the  vagina  is  thoroughly 
dilated  and  all  tendency  to  spasm  relieved,  I  have  found  a  satisfactory 
method  of  treatment.  If  the  spasm  depends  on  diseases  of  other 
organs,  these  diseases  must  be  removed  by  appropriate  treatment ;  and 
this  may  in  itself  be  enough,  or  it  may  be  necessary  to  order  the  dila- 
tors for  a  time.  Successful  cases  are  reported  of  the  cure  of  this  symp- 
tom following  the  removal  of  hemorrhoids,  and  also  of  thread-worms 
from  the  rectum,  corrections  of  uterine  displacements,  inflammations, 
and  other  similar  conditions.  Still,  the  cardinal  point  is  the  overcom- 
ing of  muscular  spasm,  and  this  can  best  be  done  by  Sims's  dilators, 
either  with  or  without  previous  cutting. 


SPASM   or   Till'.    MISCLES   OF   THE   PELVIC  ILOOll.         ol5 

Tlic  |il:iii  III"  :ill(i\\  iiii;-  cditiis  while  llic  [Kiticiit  i-  iiiidcr  •■liliu-iirnriii, 
witli  tlic  li<)|H'  that  |>rt';;ii;ui<'V  may  lltlldw,  is  not  to  bo  rccoiiiinciKlcd. 
Cocaine  lias  also  hci'ii  advised,  l)iit  on  oi'dtirintr  it  to  be  j)ainted  on  bv 
(lie  Im.-baiid,  liiiiisell"  a  medical  man,  1  was  siir|)rise(l  at  his  re|)ortin<»; 
that  the  i-ocaine,  while  destroying'  the  sensitiveness  of  the  vulva,  also 
destroyed  his  power  of  erection.  Still,  favorable  eases  have  been  re- 
ported. Hot  donehes,  sit/-batlis,  and  anodyne  a])plieations  may  be 
beiieticial,  while  the  dilators  are  also  bein»;'  used  daily.  If  ninch  irri- 
tation of  the  nnieous  membrane  around  the  vulva  exist,  ajiplieations 
of  solution!?  of  nitrate  of  silver  (1  <)-()()  o-i-.  to  3J)  often  do  ^ood. 
Tincture  of  iodine  and  ointments  of  iodoftrm  or  cocaine  mav  be  of 
use.  Simpson's  suggestion  of  cutting  the  jjudic  nerve  is  of  doidjtliil 
expediency. 

Vaginismus  Supekiok. — A  condition  of  spasm  of  the  muscles 
during  coitus,  by  which  the  penis  is  imprisoned  a\  itliiii  the  vagina,  Avas 
noticed  as  early  as  1729  by  Sehuregius.'  Others  have  noticed  it,  but 
to  Hildebrandt^  we  are  indebted  for  a  full  exposition  of  the  sulyect. 
He  maintains  that  the  spasm,  which  is  met  with  in  the  upper  part  of 
the  vagina,  is  due  to  the  contraction  of  the  levator  ani  muscle.  He 
gives  as  cause  some  irritable  or  sensitive  point  high  up  within  the 
vagina,  as  an  irritable  abrasion  of  the  cervix  or  a  tender  j)r()lapsed 
ovary.  In  the  last  edition  of  the  work  ZweifeP  takes  issue  with  Hil- 
debrandt,  and  maintains  that  the  levator  ani  alone  cannot  be  the  seat 
of  the  spasm,  as  it  does  not  encircle  the  vagina,  and  therefore  could  not 
retain  a  speculum  or  swollen  glans  penis,  as  Hildebrandt  asserts.  He 
locates  the  sjiasm  in  the  external  muscles.  This  view  would  seem  to 
be  upheld  by  a  very  remarkalile  case  of  coJue-sionis  in  coitu  rej)orted 
by  Dr.  E.  Y.  Davis,*  in  which  the  penis  Avas  so  firmly  imprisoned  dur- 
ing coitus  that  it  was  necessary  to  chloroform  the  woman  before  it  could 
be  released.  "  In  this  case  there  must  have  been  also  spasm  of  the 
muscles  at  the  orifice  as  well  as  higher  np,  for  the  penis  seemed  nipped 
low  down  ;  and  this  contraction,  I  think,  kept  the  blood  retained  and 
the  organ  erect."  Debraud,^  on  the  other  hand,  quotes  a  case  in  which 
the  contraction  was  about  t^^•o  inches  from  the  vagmal  entrance  and  a 
little  below  the  neck  of  the  uterus  and  the  vaginal  cul-de-sacs :  there 
seemed  to  be  two  nuiscular  bands  at  this  point,  one  on  each  side,  which, 
contracting,  narrowed  the  canal ;  the  contraction  was  voluntary.  I  have 
seen  spasm  of  the  levator  ani  excited  by  moving  the  ti]^  of  the  finger, 
which  had  been  introduced  into  the  vagina,  after  the  sphincter  muscles 

»  Med.  Sews,  Nov.  29,  1884,  p.  603. 

^  Hnndbuch  d.  Fraucnhrankh.,  Billroth,  1st  ed. 

^BiUroth's  Deutsche  Chirutyie,  Lf.  Ixi.  ••  Med.  Xeuy,  Pec.  13,  1884,  p.  673. 

^  "  Des  Retrecissenients  du  Conduit  A'ulvo-vaiiiiuil,"  Med.  Xews,  loc  cit. 


516  DISEASES   OF  THE   VULVA. 

had  relaxed.  The  effect  of  this  contraction  was  to  press  the  finger 
closely  against  the  lower  edge  of  the  pubes,  and  to  hold  it  quite  firmly. 
There  was  no  ring  of  contraction  encircinig  the  vagina. 

I  have  met  with  several  cases  in  which  spasm  of  some  of  the  muscles 
of  the  pelvic  floor,  accompanied  by  great  pain,  came  on  suddenly  with- 
out any  apparent  cause,  most  often  during  sleep.  This  spasm  in  one 
case  seemed  to  affect  the  internal  sphincter  ani  muscle,  and  unless 
relieved  would  last  almost  continuously  for  days.  It  was  easily  stopped 
by  a  suppository  or  rectal  injection  containing  opium.  It  seemed  in  this 
case  usually  to  follow  diarrhoea  and  to  be  accompanied  by  constipation. 
Hildebrandt  has  met  with  similar  cases. 

The  treatment  of  these  rare  forms  of  spasm  has  already  been  alluded 
to  in  the  text.  All  irritable  tender  points  must  be  relieved.  Section 
of  the  affected  muscles  has  been  suggested,  as  well  as  neurotomy,  but  it 
is  little  likely  to  be  of  use.  When  the  spasm  is  continuous,  relief  may 
be  obtained  by  anodynes  applied  as  near  the  affected  muscle  as  possible. 
The  bowels  must  be  carefully  regulated,  and  all  sources  of  irritation 
removed,  wliile  the  general  health  is  carefully  looked  to. 

COCCYODYNIA  OR  OOCCYGODYNIA. 

This  is  a  rather  frequent  painful  affection  of  the  muscles,  tendons, 
and  nerves  of  the  os  coccyx,  with  or  without  disease  of  the  bone  itself. 
It  was  originally  described  by  Nott,  but  was  overlooked  and  nearly 
forgotten  until  1861,  when  a  knowledge  of  it  was  revived  by  Simp- 
son and  Scanzoni. 

Cause. — Unquestionably,  childbearing  is  the  most  frequent  cause,  but 
it  may  undoubtedly  occur  in  women  who  have  never  borne  children 
and  in  men  and  young  children.  Other  causes  are  mechanical  vio- 
lence, as  a  kick,  blow,  or  fall  upon  the  coccyx,  or  horseback  riding ; 
uterine,  ovarian,  and  rectal  disease ;  cold  and  exposure,  especially,  as 
pointed  out  by  Simpson,  when  conjoined  with  the  rheumatic  diathesis. 

Pathology. — Displacement,  fracture,  and  caries  of  the  coccyx  have 
frequentlv  been  noted.  But  something  more  than  a  dislocation  of  the 
bone  is  necessary,  as  every  gynecologist  must  have  frequently  observed 
such  dislocations  without  any  accompanying  pain.  Hyrtl  found  thirty- 
two  cases  of  luxation  of  the  bone  with  ankylosis  in  one  hundred  and 
eighty  pelves — a  number  far  greater  than  the  corresponding  cases  of 
coccygodynia.  There  must  be,  then,  conjoined  with  the  disease  or 
displacement  of  the  bone  a  hypera^sthetic  or  neuralgic  state  of  the 
tendons  or  ligaments  attached  to  the  bone.  This  may  be  due  to  a 
chronic  inflammation  of  the  tendinous  structure,  or  a  direct  involve- 
ment of  the  nerves  themselves.  As  this  condition  of  the  structures 
involved  may  exist  without  any  displacement  or  disease  of  the  bone, 


COCcynDYMA    nil  (OCCYanhV M.\.  .',17 

So  wi'  i>tt<ii  liiiil  tlif  Ijiiiii',  so  far  a>  we  can  <li.si'oVfr,  iti  every  n-iM-*! 
iionual.  ( )ii  tlir  tttlicr  hand,  the  Ijoiic  may  Ixj  tlie  real  s«,'at  ot"  tlic 
(liseaso,  caries  existing,  and  tlio  syiujitoms  refusing;  to  yield  until  the 
diseiLsctl  bone  is  removed.  A  number  otsueh  eases  have  Ix-fn  reported. 
Rheumatism  ol"  the  muscles  or  tendons  Iuls  l)een  observetl,  the  disease 
iK'intr  accomj>auied  by  other  rheumatic;  manifestations,  such  as  liunbafo 
or  muscidar  rheumatism  in  other  parts.  Uterine  and  ovarian  di.s<'a.se 
may  al-o  be  the  start ini(- point. 

Sifiitj»fi)iiis. —  Pain  in  the  reirion  of  the  coccyx,  a<r<jravate<I  bv  anv 
motion  which  brings  into  action  the  mu.seles  attachcfl  to  the  c<k-cvx, 
is  the  principal  symptom.  Tiie  patient  suffers  on  .>»ittinjr  down  and  on 
risiui:;  attain,  espcrially  if  she  maintains  the  sittin<r  position  for  long. 
Deflation  is  often  a<r<>nizing,  and  coitus  almost  unendurable;  sometimes 
even  walking  will  increase  the  pain.  The  patient  is  often  obliged  to  sit 
on  the  side  edge  of  the  chair,  so  as  to  avcjid  pressure  on  the  bone,  and 
to  use  the  arms  and  hands  as  aids  in  getting  up. 

Diagnosis. — The  conditions  from  Avhich  this  must  be  di.stingui.shed 
are  diseases  of  the  rectum  and  anus,  neuralgia  of  the  sacral  nerves,  and 
hysteria.  A  physical  examination  will  generally  serve  to  make  the 
diagnosis.  With  one  finger  in  the  vagina  or  rectum  and  the  thumb 
outside,  the  lione  can  be  seized  and  moved,  when  the  characteristic  j)ain 
will  be  produced.  Pressure  on  the  bone  through  the  skin  will  also  pro- 
voke pain.  Negative  evidence  will  be  the  absence  of  di.sease  in  the  rec- 
tum and  of  pain  on  pressure  over  the  inner  surface  of  the  sacrum.  The 
hysterical  counterpart  of  the  disease  may  be  distinguished  by  absence  of 
fracture  or  caries,  and  by  "noting  the  irregularity  of  the  pain  in  the 
hysterical  affe<-tion,  an  indescribable  affectation  of  suffering,  and  the  lack 
of  consistency  in  the  behavior  of  the  symptoms  "  (Goodell). 

Pror/nosis. — The  disease  shows  little  tendency  to  spontaneous  recov- 
ery, but,  fortunately,  nearly  all  cases  can  be  cured  by  proper  nueasures. 

Treatment. — The  hysterical  form  mast  be  treated  by  agents  directed  to 
the  general  condition  of  the  nervous  svstem,  as  well  as  to  the  rennjval 
of  any  uterine  or  ovarian  disease.  The  rheumatic  form  must  be  treated 
by  remedies  directed  toward  that  condition,  together  with  careful  atten- 
tion to  diet  and  exercise.  Counter-irritation  by  the  actual  cauter}*  or  blis- 
ters will  also  do  good  in  this  form.  In  the  milder  forms  of  the  disease 
the  endermic  use  of  morphia,  the  use  of  ointments  of  veratria  and 
aconite,  should  be  tried.  Electricity'  has  been  successfully  emplove<l — 
a  mild  galvanic  current  with  one  pole  (— )  in  the  rectum  and  the  other 
(+)  on  the  outside.  In  rheumatic  cases  faradization  is  generallv  likelv 
to  do  more  good.  Should  all  these  measures  fail,  a  more  radical  plan 
may  be  adopter!.  We  have  two  operations — separation  of  the  coccvx 
from  all  its  tendinous  or  muscular  attachments,  and  total  extirpation 
of  the  bone.     The  first  plan  was  proposed  by  Simpson,  the  last  bv  Xcjtt. 


518  DISEASES   OF  THE   VULVA. 

The  separation  of  the  ligaments  is  to  be  clone  subcutaneoiisly,  A 
tenotome  is  introduced  under  the  skin  near  the  end  of  the  bone;  it  is 
then  carried  up  over  the  bone  with  its  flat  side  toward  the  outer  surface, 
until  the  point  is  above  the  sacro-coccygeal  articulation  ;  it  is  then  car- 
ried to  one  side  of  the  bone,  and  turned  so  that  its  cutting  edge  is 
toward  the  rectum,  and  withdrawn,  severing,  as  it  passes,  all  the  tissues 
attached  to  the  side  of  the  bone.  It  is  then  carried  up  on  the  other 
side  and  the  operation  repeated.  The  second  side  may  be  cut  without 
taking  the  knife  entirely  out  of  the  wound.  If  a  hypodermic  injection 
of  coqaine  into  the  affected  part  (lOlTL  of  a  4  per  cent,  solution)  be  given 
just  before  operating,  no  pain  at  all  will  be  experienced.  The  writer 
has  performed  this  little  operation  several  times  with  fairly  good  results. 
If  it  fail  to  give  relief,  the  plan  suggested  by  Dr.  Thomas  may  be  tried. 
He  cuts  down  upon  the  bone,  raises  it  with  the  finger,  and  severs  all  its 
attachments  with  scissors. 

When  the  bone  is  carious,  and  in  other  cases  where  milder  means 
have  failed,  Nott's  operation  is  the  only  one  which  offers  any  prospects 
of  relief.  The  bone  is  laid  bare,  its  attachments  severed,  and  the  bone 
disarticulated.  It  will  be  found  convenient,  after  cutting  down  to  the 
bone,  to  disarticulate  it  first  and  enucleate  it,  as  it  were,  beginning  at 
the  base  and  finishing  with  the  point.  "  A  hea\y  pair  of  forceps  is 
necessary  to  hold  the  bone  and  lift  it  up  while  the  attachments  are  cut 
with  scissors.  The  resulting  wound  must  be  left  to  heal  by  granula- 
tion, a  drainage-tube  being  left  in  place  for  several  days  to  ensure  a 
free  discharge  from  the  cavity,  and  antiseptic  injections  used  as  long  as 
there  is  any  discharge.  I  have  operated  several  times  with  complete 
relief  to  the  symptoms,  though  they  had  lasted  for  years.  Many  other 
successful  cases  have  been  reported. 

New  Growths  op  the  Vulva. 

Lupus  of  the  Vulva. — Dermatologists  describe  two  forms  of  this 
disease,  L.  erythematosus  and  L.  vulgaris.  The  first-named  does  not 
seem  to  occur  on  the  vulva,  the  face  and  scalp  being  its  favorite  seat. 
This  form  is  non-ulcerative. 

Lupus  vulgaris,  Esthiom^ne. — Duhring  describes  lupus  vulgaris 
to  be  "a  cellular  new  growth  characterized  by  variously  sized  and  shaped 
reddish  or  brownish  patches,  consisting  of  papules,  tubercles,  or  flat  in- 
filtrations, usually  terminating  in  ulceration  and  cicatrices."  If  the 
tubercular  nature  of  the  affection  be  admitted,  we  must  consider  it 
rather  as  a  specific  inflammation  than  a  new  'growth.  With  this 
exception  it  is  well  to  keep  the  definition  in  mind,  as  it  will  help  to 
exclude  certain   affections  wrongly  described  as  lupus. 


NEW   Cliowrils   OF    IIIK    177.  IM.  :,\\i 

J'Wtjincitfi/. —  I  >(  riii:il()l()i;i,^t>  dcchirc  |)i"iiii;iry  Iii|iii-  ol"  llic\iilva  U> 
be  fXft'cdiiiuly  raic  ;  iiiaiiy  aiitlj(»i"s  do  iidt  even  mention  it;  hut,  as 
mij::lit  1h'  ('Xpcctcd,  the  jiyii('C()li)<;ists  meet  with  it  more  coriiinonlv. 
Dimcau  and  Tait  both  (Icdai'c  that  they  have  met  with  it  (piitc  often, 
the  hitter  most  often  in  |»ri\ate  |)ractict',  the  lorniei-  in  hospital-.  In 
this  country  it  must  be  rai-e,  as  it  is  scarcely  menti<»ncd  in  ^;ynccoh(<r- 
ical  ti'xtbooks  (»!'  American  orijiin.  Tlie  writer  has  met  with  it  but 
once.  The  frecjuencv  asserted  by  Duncan  an<l  'I'ait  mnst  l)c  ascribed 
to  their  coiisich'rinLT  as  hipus  certain  concbtions  not  so  considered  bv 
other  authorities/  Probably  less  than  fifty  cases  have  been  re])orted 
all  tojjether. 

A(j('. — The  disease  on  other  })arts  of  tiic  body  seems  to  affect  the 
vcrv  young,  though  rarely  observed  before  the  second  year  of  life. 
Of  cases  occurring  on  the  vulva  in  Taylor's  table,^  the  youngest  was 
thirteen  and  the  oldest  fifty-six.  Tlie  period  of  greatest  liability, 
according  to  West,  is  between  twenty  and  thirty. 

Etiology. — Attempts  have  been  made  to  show  that  all  the  cases  of 
ulceration  around  the  vulva  described  as  lupus  are  in  reality  due  to 
syphilis.  This  attempt  has  failed,  as  Taylor^  has  well  shown.  As 
has  already  been  mentioned,  the  tendency  of  late  has  been  to  class  this 
disease  rather  with  the  inflammatory  affections  than  with  new  growths. 
Recent  experiments  would  seem  to  point  to  a  specific  germ,  the  bacillus 
tuberculosis,  as  its  cause,  thus  grouping  it  with  tubercular  inflamma- 
tion— a  class  of  diseases  now  well  recognized  as  much  more  common 
than  was  formerly  supposed. 

Koch,  Cornil,  Doutrelepont,  and  others  have  shown  the  presence  in 
lupous  tissues  of  all  sorts  of  a  bacillus  identical  with  that  found  in, 
and  supposed  to  be  causative  of,  true  tubercle.  These  bacilli  are  very 
scanty,  but  still,  it  is  asserted,  are  always  present.  Inoculation  with 
these  same  tissues  has  produced  tuberculosis  in  the  lower  animals. 
Artificial  cultivations  of  the  liacillus  obtained  from  lupus,  extending 
over  many  months,  have  retained  their  identity  and  their  power  of 
inoculation.  These  facts  in  the  pathology  of  the  disease,  if  accepted, 
are  of  great  importance  in  their  bearing  on  therapeutics. 

The  existence  of  a  peculiar  diathesis,  the  scrofulous,  has  been 
asserted  *  to  exist  in  proportions  varying  from  30  to  60  per  cent,  in 
cases  of  lupus.  In  certain  cases,  on  the  contrary,  perfectly  good 
health  has  been  specially  noted.  Accepting  the  infection  theory,  we 
naturally  look  for  the  cause  in  the  direct  inoculation  of  the  specific 
bacillus,  together  with  a  certain  jjredisposition  or  diathesis  which  en- 
ables the  bacillus  to  retain  a  foothold  once  obtained,  and  to  grow  and 
multiply.     But  even  admitting  this  to  be  true,  it  only  partially  ex- 

'  See  Obstetrical  Trans.,  1885,  pp.  24:^--2.")0.  ^  Gi/n.  Trans.,  18S1,  p.  210. 

^  Loc.  cit.  *  J.  C.  White,  BcfUni  M.  and  S.  Journ.,  vol.  cxiii.  p.  409. 


520  DISEASES  OF  THE   VULVA. 

plains  the  phenomenon ;  for  this  manifestation  of  the  bacillary  inva- 
sion is  so  different,  anatomically  and  clinically,  from  that  ordinarily 
seen  in  other  forms  of  tuberculosis,  that  some  modifying  condition,  not 
yet  understood,  must  be  supposed  in  order  to  account  for  it.  While  the 
bacillus  of  lupus  will  produce  tuberculosis,  lupus  has  not  yet  been  pro- 
duced by  any  form  of  artificial  inoculation.  The  source  of  the  bacilli 
is  not  far  to  seek.  The  spores  are  found  to  be  present  in  all  places 
where  phthisis  exists,  so  that  only  a  superficial  excoriation  or  abrasion 
is  necessary  to  give  a  point  of  entrance.  Once  engrafted  into  the  tis- 
sues, it  grows  and  disseminates  itself,  but  only  very  slowly  and  appar- 
ently with  great  difficulty.  Should  it  gain  access  to  the  circulation,  a 
general  tuberculosis  may  follow.  If  we  reject  the  theory  of  a  specific 
bacillus,  we  know  nothing  of  the  causation  of  this  disease. 

Pathological  Anatomy. — Virchow  grouped  lupus  with  the  granulo- 
mata,  and  the  lesion  does  seem  to  resemble  granulation  tissue.  It  affects 
mostly  the  cutis  or  mucosa,  sometimes  penetrating  the  deeper  structures, 
but  never,  apparently,  affecting  bone.  Lupus  in  other  parts  of  the 
body  occurs  mostly  in  nodules  or  tubercles.  Dr.  Thin,  however,  asserts 
that  in  the  vulva  it  is  rather  difftised  through  the  tissues,  like  any 
chronic  inflammation,  the  greater  number  of  cells  being  in  the  neigh- 
borhood of  the  vessels.  Here  we  find  a  thick  infiltration  of  leucocytes, 
the  infiltration  tending  to  spread  and  coalesce  with  neighboring  foci. 
The  infiltrated  tissue  tends  to  form  new  tissue,  which  in  turn  may  ulcer- 
ate. There  may  be  also  an  excessive  formation  of  epithelial  or  epider- 
mic cells  over  the  affected  part,  with  exfoliation.  Mixed  with  the  small 
cell-infiltration  there  are  also  certain  epithelioid  and  giant-cells.  The 
tubercle  bacilli  may  be  found  in  the  tissues  after  proper  preparation, 
but  sometimes  an  immense  number  of  sections,  forty-seven  in  one  case 
(Gushing),  may  be  necessary  before  they  can  be  recognized.  There  is 
but  little  tendency  to  cheesy  degeneration,  in  which  respect  this  tissue 
differs  greatly  from  tubercular  tissue  found  elsewhere.  There  is  always 
more  or  less  hypertrophy  of  surrounding  tissue,  and  in  some  cases  the 
tubercles  are  heaped  together  like  strawberries  (Taylor),  which  masses 
may  in  turn  coalesce  with  larger  masses. 

Clinical  History. — Duncan  makes  two  principal  forms,  L.  minimus 
and  L.  maximus.  The  former,  he  says,  occurs  mostly  within  the  vulva, 
and  may  on  superficial  examination  be  mistaken  for  urethral  caruncle 
or  eczema  of  the  vestibule  or  pruritus  pudendi.  In  another  place,  how- 
ever, he  expresses  his  doubt  as  to  the  identity  of  these  slight  cases  with 
true  lupus.  Without  a  microscopic  examination  of  the  tissues  or  a  more 
detailed  description  we  must  admit  his  doubts  as  the  truth. 

Clinically,  we  may  make  three  principal  divisions :  1,  Lupus  ser- 
piginosus,  ulcerans,  or  exulcerans ;  2,  lupus  perforans ;  3,  lupus 
prominens. 


Mjw  anownis  (jf  tui:  vii.va.  o-ii 

LiifiUf  st'r/ilt/liiosii.s. — In  this  fonii  the  -iipcrtici.-il  tissius  stt'in  to  Ijr 
tilt'  ones  ntl'fctcd.  Tlic  l:il)ia  niajnra,  i>r  tlic  <t<:im'  iM-twci'ii  tlic  lal)ia  and 
tlu'  tliiiili,  arc  nttcn  tin-  |Kirt-  lii'.-t  attached  (Taylor).  Soinctinjcs  tlic 
discasi'  Ix'irins  on  tlic  cervix  or  within  the  va;,'^ina,  and  works  its  wav 
oiitwaivl.  Px'uiiinin;^-  as  a  small  tiiherclc,  or  tid)crcles,  «»f"  a  i"cddi.-h  or 
hrow  iii-li  color,  the  disease  {iradnally  c\tcnd>,  the  atf'eetcd  ti.-.-ncs  hreak- 
intr  down  into  idccrs,  which  s|)rcad  nntil  the  labia,  nions,  and,  in  Tact, 
the  whole  vulvar  and  anal  rc<iions,  are  involve(l  in  one  extensive  jiatch 
of  tid)ei'cular  ulceration.  In  the  centi"al  ]»ortion  ol'  the  di-(a~ed  |»ai1> 
cicatrices  may  iorm,  in  turn  to  i)e  atiaiu  attacked  and  destroye<l,  or  the 
healin<i:  process  may  extend  and  he  ])ermanent.  In  some  of"  the  eases 
granulations  sprin<>:  up  around  the  ulcers,  ^iivinu-  the  form  known  as 
lupus  hypertroj)hicus. 

LujjKs  j/crjorans. — The  disease  sometimes  shows  a  tendency  to  attack 
the  deeper  tissues  rather  than  the  supcrfieial,  undermininjr,  and  finally 
destroyinij:,  the  overlyiuu'  ])atches.  In  this  way  the  rectum,  vajrina, 
and  Madder  may  be  attacked,  and  g-reat  destruction  caused  in  the  deep 
tissues,  forming  large  caverns  with  perhaps  only  small  external  open- 
ings. These  forms  may  coexist,  as  Huguier,  t<j  whom  we  owe  the  first 
(1848)  descripti(jn  of  the  disease,  points  out.  He  describwl  and  pic- 
tured a  case  with  deep  perforating  ulcer  of  the  vulva,  and  sujx-rficial 
ulcerations  around  the  anus,  with  great  hyj)ertrophy. 

In  lupus  promiiuns  the  tubercles  seem  to  be  the  distinctive  feature. 
They  grow  and  coalesce,  forming  large  bright  scarlet  or  reddish,  and 
sometimes  brownish-purple,  masses  as  large  as  half  of  an  e^rvr  cut  in  its 
long  axis  (Taylor).  These  masses  may  be  several  inches  long,  and  six 
or  eight  of  them  may  coexist  (Fig.  178).  This  form  seems  to  affect 
mostly  the  outside  of  the  vulva. 

In  all  the  forms  there  is  more  or  less  hypertrophy  of  the  labia  minora 
and  majora,  and  the  clitoris,  or  even  the  whole  vulva  may  lie  simi- 
larlv  affected.  This  is  entirely  inde])endent  of  the  gro^vth  of  true  luj>ous 
tissue  in  the  ])arts,  though  of  course  the  lupus  must  antedate  the  hyj)er- 
trophy.  The  enlarged  parts  are  then  hard,  pale,  or  dull  white.  The 
hypertrophy  remaining  after  the  disease  is  of  a  similar  nature. 

The  discharge  from  the  ulcers  varies.  In  some  cases  there  is  "  laud- 
able "  pus,  in  others  a  sero-pus,  and  in  some  only  a  watery  discharge. 
Some  of  the  cases  seem  to  have  a  great  tendency  to  hemorrhage.  ^lat- 
thews  Duncan  describes  a  form  of  the  disease  which  he  calls  lieme»r- 
rhagic  lupus,  and  reports  four  cases.'  The  microscopic  examination 
of  these  cases  shows  a  different  histological  structure  from  ordinaiy 
lupus.  This  form  is  generally  insensitive,  but  occasionally  is  tender 
and  painful.  He  reports  one  casew^here  the  hemorrhages  extende<l  over 
fourteen  years.     The  hemorrhages  may  l)e  long  and  slight,  or  short  and 

*  Edin.  Mid.  Journ.,  .July.  1SS4. 


522 


DISEASES   OF  THE   VULVA. 


very  severe.     Dr.  Duncan  considers  this  disease  to  be  allied  with  senile 
vaginitis.     From  his  descriptions  it  can  hardly  be  a  true  lupus. 

Symptoms. — The  symptoms  of  ordinary  lupus  are  almost  none.     In 
many  cases  the  patient  seems  to  be  in  perfect  health;  in  the  majority 

Fig.  178. 


B 


Lupus  Prominens  :  A,  hypertrophied  labia  minora;  B,  after  application  of  escharotics. 

of  cases  there  is  little  pain.  If  the  rectum  or  other  passages  are 
aifected,  there  may  be  stricture  or  fistulee  with  attendant  symptoms. 

Prognosis. — Lupus  is  seldom  a  fatal  disease.  It  runs  a  very  long 
and  chronic  course,  and  in  a  small  percentage  of  cases  ends  in  spon- 
taneous recovery.  A  still  larger  number  are  cured  by  appropriate 
treatment.  Taylor  collected  the  statistics  of  21  cases  :  6  were  cured ; 
7  relieved,  4  not  relieved,  and  4  died.  From  this  we  see  that  nearly 
two-thirds  were  cured  or  relieved. 

Diagnosis. — The  diseases  most  likely  to  be  confounded  with  lupus 
are  cancer,  syphilitic  ulceration,  ulcerative  chancroid,  and  elephantiasis. 
From  cancer  it  can  be  diagnosed  by  its  extreme  slowness  of  growth, 
often  great  hypertrophy  of  surrounding  tissues,  and  prominent  tuber- 
cles. The  general  health  of  the  patient  is  good,  and  there  is  absence 
of  general  symptoms.  The  presence  or  absence  of  pain  is  not  to  be 
depended  on  as  a  distinguishing  mark.  From  syphilitic  disease  the 
affection  is  distinguished  \vith  more  difficulty,  but  the  histor}^  of  the 
case   and   the    behavior    under   treatment   will    give    aid.     Extensive 


.v/.ir  enow 'JUS  or  riii:  vilva.  .02;J 

sy|iliilitic  iilcrrntinii  nl'  ilic  \iil\:i  i^  even  iiiorc  rai-c  iliaii  true  liipii--. 
I'lia^t'tlniic  cliaiii'if  i>  iniicli  iimrc  i;i|>i<l  in  its  <;i(i\\tli,  :iii<l  tlic  coldr 
<»('  tlic  Ikisc  is  iiittri'  n-niy  and  ycllnw  i.-li-\vliitc  tluui  in  lupus.  When 
clcai-cd  ()t"»lis(liar<i't'  the  l)asc  is  red.  ( "lianci-<tid  lias  none  of  (lie  iliick- 
cniui;,-  of  >iirr(inn(linM-  (is>ii(',  ami  tnlicrdi'  lui'niatinn  is  waiilin;.^;  tlio 
liistory  will  also  scrvt'  to  cxclndc  it.  in  ln|)us  the  in<:ninal  inlands 
arc  seldom  if  over  enlarircd.  Tlu'  examination  of  the  diseliarnes  for 
l)acillii>  (iil»ercnlosis  with  an  ailirmatixc  I'e.-ult  will  he  deeisixc,  hut  a 
nciiative  result  will  prove  nothing-.  It  is  not  to  he  forp»tten  that  ean- 
eerons  disease  may  develoj)  on  lupous  tissue  and  ohseure  the  diatrnosis. 

Treatincid. —  Internal  medication  will  accomplish  hut  little.  There  is 
no  specific  for  this  disease.  The  drui^s  which  have  hecn  mo.st  used  are 
arsenic,  itidinc,  and  mercury,  the  so-called  alteratives,  toirether  with 
agents  supposed  to  have  an  eflect  on  the  strumous  diathesis — cod- 
liver  oil  and  iron.  Their  use  has  {)rovcd  unsatisfactory,  and  thev  can- 
not he  depended  on  to  the  exclusion  of  local  and  surgical  treatment, 
which  offers  almost  the  only  hope  of  success. 

Acting  on  the  parasitic  theory  of  the  disease,  recent  authorities  have 
recommended  the  antiseptic  method  of  treatment ;  and  if  the  methods 
of  the  older  writers  be  examined,  it  will  he  found  that  the  most  success- 
ful have  heen  those  which  are  in  harmony  with  this  idea.  If  we  con- 
cede that  lupus  is  a  form  of  tuberculosis,  and  that  tuberculosis  is  due  to 
the  presence  of  a  bacillus  in  the  tissues,  the  only  rational  plan  is  to  use 
such  agents  as  will  destroy  the  cause.  Koch  by  his  investigations  has 
shown  which  are  the  agents  most  potent  against  the  parasites ;  among 
them  he  names  mercuric  chloride  first,  and  chlorine,  iodine,  and  bro- 
mine Maters  in  the  order  named. 

Doutrelepont  in  1884  tried  the  bichloride,  and  was  quickly  followed 
bv  others  in  trials  of  this  agent,  as  well  as  of  others  of  a  similar  nature, 
such  as  sulphurous,  carbolic,  and  salicylic  acids,  Veiy  successful 
results  have  been  recorded  by  the  dermatologists  with  lupus  on  other 
parts  of  the  body,  but  so  far  the  writer  has  seen  no  reports  from  the 
gynecologists.  This  is  due,  doubtless,  to  the  rarity  of  the  cases.  Dr. 
J.  C.  AVhite^  reports  twelve  cases,  mostly  affecting  the  upper  extremi- 
ties. His  plan  of  treatment  was  to  use  a  sublimate  solution  (i— 1  gr. 
to  .sj\  applied  for  half  an  hour  night  and  morning,  followed  by  an  oint- 
ment of  the  same  (gr.  j  to  sj).  Xear  the  mucous  surfaces  he  found 
salivation  easily  induced,  but  on  the  skin  no  such  trouble  was  encoun- 
tered. His  conclusions  are  very  positive  as  to  its  curative  effect :  "  If 
its  use  be  contiiuied  long  and  thoroughly  enough,  a  point  not  yet  sutti- 
eiently  determined,  I  see  no  reason  to  doubt  its  absolute  power  over  the 
parasitic  nature  of  lupus." 

Mr.   Hutchinson  has  strongly  recommended    sulphurous  acid,  and 

'  Boston  Med.  and  Surg.  Joum.,  Oct.  29,  1885. 


524  DISEASES   OF  THE   VULVA. 

Marshall  has  advised  salicylic  acid.  Lately,  iodol  has  been  used  with 
success.  A  10  per  cent,  ointment  of  pyrogallic  acid  is  highly  recom- 
mended. It  attacks  only  the  diseased  tissues,  which  it  turns  black.  It 
must  be  repeated  several  times. 

Surgical  interference  has  been  generally  recommended.  This  has 
included  the  excision  of  the  diseased  parts  as  far  as  possible,  scraping 
with  a  sharp  spoon,  scarification,  the  application  of  the  red-brown  cau- 
tery, the  more  extensive  destruction  of  tissue  by  the  white-hot  point, 
and  boring  the  tissues  with  points  of  silver  nitrate  :  all  these  methods 
have  their  uses.  The  soft  tissues  can  be  scraped  away  with  the  spoon, 
and  the  sublimate  solution  applied  to  the  diseased  surface,  thus  bring- 
ing it  in  contact  with  deeper  portions  of  tissue  and  hastening  the  cure. 
Large  hypertrophic  masses,  which  would  shut  in  diseased  surfaces  and 
prevent  their  proper  treatment,  may  be  excised.  There  is  but  slight  dan- 
ger of  hemorrhage,  as  bleeding  points  can  be  picked  up  by  haemostatic 
forceps  as  the  incision  is  extended.  There  is  little  hope  of  getting  pri- 
mary union  after  such  incisions,  and  probably  brushing  over  the  cut 
surfaces  of  tissue  with  the  cautery  may  be  a  wise  precaution,  as  it  is  not 
to  be  forgotten  that  after  any  cutting  operation  on  lupous  tissue  a  gen- 
eral tubercular  infiltration  is  possible.  Lately,  Pick  of  Prague  has  rec- 
ommended^ cauterization  by  electrolysis.  The  tissues  being  first  painted 
with  cocaine,  the  positive  current  is  applied  to  the  surface  with  a  bare 
metallic  electrode.  In  this  way  the  tissues  are  destroyed  almost 
painlessly. 

Elephantiasis  Aeabum  (Pachydermia). — The  pathology  and 
etiology  of  the  affection  usually  described  under  this  head  seem  to  differ 
so  much  in  the  diiferent  descriptions  of  individual  cases  that  it  would 
appear  as  if  two  distinct  diseases,  closely  resembling  each  other  in 
many  points,  but  still  with  marked  differences  both  in  cause  and 
mode  of  growth,  have  been  confounded.  The  first  of  them  is  the 
true  elephantiasis  arabum,  and  the  other  we  may  best  define  as 
fibroma  diffusum. 

The  generally  accepted  definition  of  elephantiasis  as  given  by  Duhr- 
ing  is  as  follows  :  "  It  is  a  chronic  hypertrophic  disease  of  the  skin  and 
subcutaneous  connective  tissue,  characterized  by  enlargement  and  deform- 
ity of  the  part  affected,  accompanied  by  lymphangitis,  swelling,  ccdema, 
thickening,  induration,  and  papillary  growth."  Following  the  statement 
of  Schwimmer,  most  modern  authorities,  especially  the  German,  hold 
that  the  erysipelatoid  attacks,  by  which  true  elephantiasis  arabum  of  the 
extremities  is  characterized,  are  absent  in  elephantiasis  of  the  vulva. 
This  statement,  however,  I  cannot  find  to  be  confirmed  by  those  who 
have  observed  the  disease  in  tropical  climates,  and  therefore  must  hold 
1  Med.  Press  of  Western  New  York,  March,  1887. 


.v/;ii'  (Uiowriis  OF  TiiF.   vriA'A.  020 

tliiil  the  (lIscMSc  ticscrilxil  \>\  I  lie  (  Icniiaiis  ditlci'.-  in  llii-  if.<|M'<t,  ;i.-  well 
as  ill  (itlicrs,  IVkiii  the  tnic  (  )iMciit;il  Ixpc 

AiKttlicr  |»i)iiit  dl"  (litVcri'iicc  is  foiiiid  in  the  cmiix'.  I^l(j)li:iiiti:i.-is 
arahiiiu  is  now  <|iiilc  generally  a<linitt<'(l  to  l)c  (Ik-  ronit  ni"  a  |»arasitt', 
which  is  ((»  l)c  t'oinid  at  rci-taiii  times  in  the  alVcctcd  part,  while  no 
such  cause  can  he  discdxci'cd  in  the  (Usease  as  (h'sci'ilx'd  and  seen  in 
Nofthern  Kurojtc  and  this  country.  (citain  anatomical  diHerencos 
also  exist   which   will    he  descrihed    later  on. 

llnhUdt. — The  disease  is  very  rare  in  the  Northern  portion.-  of  the 
United  States,  hut  is  a  little  more  common  in  the  Southern  States, 
esjK'cially  anion^-  the  e(»lored  race.  In  certain  countries  ir  is  endemic, 
especially  in  low-lyino-  districts,  sea-coasts,  and  islands.  It  is  verv 
trc([nent  in  tiie  West  Indies,  some  ])ortions  ot"  South  America,  Africa, 
India,  ami  other  tropical  climates. 

FAioUxjy. — The  cause  of  the  disease  is  an  inllammation  and  oUstrnc- 
tion  of  the  lymphatics  (Dnhring-) ;  and  this  has  been  attrihuted  '  to  the 
presence  in  the  blood  and  lymphatics  of  the  Filaiue  s(ni(/iiinis  /loiitlnia 
and  its  ova.     The  disease  is  not  contagious  or  hereditary. 

Pdthohf/ical  Anatomi/. — The  principal  lesion  seems  to  consist  in  an 
immense  proliferation  of  the  connective  tissue,  with  a  orcat  amount  of 
serous  iniiltration.  The  skin  or  mucous  mend)rane  coveriuir  the 
affected  part  is  also  increased  in  thickness,  the  papillae  enlarged,  tmd 
the  epidermis  thickened.  There  is  also  a  certain  amount  of  pigmenta- 
tion. The  skin  may  be  smooth  or  rough  from  papillary  enlargement 
(,)r  warts.  Late  in  tlie  disease  the  nervous  substance  is  destroyed. 
The  lymjihatic  glands  are  swollen,  and  the  lymphatics  greatly  dilated 
and  distended  with  fluid,  their  walls  thickened  and  of  a  light-yellow 
color.  In  those  cases  where  the  lymphatics  are  not  affected  the  veins 
will  be  foiuid  markedly  dilated,  with  distinct  hyperplasia  of  the  ad- 
ventitia.- 

Sympfom.'<. — The  disease  is  stated  generally  to  begin  with  ervsipela- 
toid  inflammation  of  the  parts,  Avith  fever,  pain,  heat,  and  swelling. 
Such  an  attack  is  followed  liy  a  slight  enlargement,  and  is  succeeded 
by  other  attacks  until  eulargement  becomes  more  marked  and  j)erma- 
nent.  At  the  end  of  about  a  year  these  attacks  cease  and  the  growth 
from  that  time  on  is  gradual.  The  parts  of  the  vulva  generally 
attacked  are  the  labia  majora,  clitoris,  and  labia  minora.  The  growth 
increases  enormously,  often  reaching  fortv  to  fiftv  ])onnds  in  weight 
and  hanging  down  to  the  knees  or  ankles.  Reyer^  has  published  a 
large  number  of  cases  collected  in  Egy})t.  The  tumors,  he  states,  are 
often  enormous  and  last  twenty  years  or  more.  He  describes  these 
tumors  as  having  a  small  navel-like  depression'  in  the  upper  third, 

'  Fayrer,  Lnnrrf,  Feb.,  1879.  ^  Sclnvimmer,  Handbook  of  Shin  Dis.,  Zieinssen. 

^  Quoted  in  Zieinssen. 


526  DISEASES  OF  THE   VULVA. 

which  reaches  down  to  the  entrance  of  the  vagina.  The  surface  may- 
be smooth  or  rough,  warty,  fissured,  and  ulcerated.  Eczematous  erup- 
tions are  not  uncommon  on  the  aifected  part.  Maceration  of  the  epi- 
dermis takes  place  from  the  moisture  of  the  parts,  especially  in  the 
folds  of  the  skin.  An  oozing  of  lymph  also  occurs  from  minute  open- 
ings in  the  skin,  as  well  as  from  the  ulcerated  surfaces.  ExcejDt  from 
the  weight  and  discomfort,  and  the  impossibility  of  gratifying  the  sex- 
ual desire,  the  tumors  do  not  seem  to  aifect  the  general  health  of  the 
patients.  The  inguinal  glands  are  always  swollen  and  enlarged,  and 
occasionally  form  small  tumors  in  the  groin  which  sometimes  admit  of 
the  escape  of  lymph  (Schwimmer). 

Prognosis. — The  prognosis  as  to  recovery,  once  the  disease  is  well 
developed,  is  hopeless.  It  is  stated  that  recovery  occasionally  occurs 
in  young  subjects  early  in  the  disease.  The  affection  runs  an  indef- 
inite course,  and  while  it  does  not  ordinarily  prove  fatal,  the  wretched 
condition  of  the  victim  is  often  worse  than  death.  When  fatal  the 
result  is  brought  about  by  thrombosis  and  pysemia. 

Diagnosis. — True  elephantiasis  arabum  must  not  be  confounded  with 
fibroid  enlargements  and  hypertrophies  of  the  parts,  which  are  more 
commonly  met  with  in  this  country  than  the  true  disease.  In  these 
cases  the  resemblance  is  often  striking,  but  some  of  the  conditions  are 
wanting — either  the  history  of  inflammatory  attacks  at  the  beginning, 
or  the  enlarged  glands  in  the  groin,  or  the  general  diffusion  of  the 
tumor,  with  thickening  of  the  true  skin  over  the  growth.  The  absence 
of  these  sio;ns  will  serve  to  distinguish  it  from  fibroma  diffusum  or 
from  simple  fibroma,  with  which  it  has  often  been  confounded.  Vir- 
chow  states  that  true  elephantiasis  never  becomes  pediculated,  but 
always  involves  the  whole  organ.  It  also  contains  yellow  elastic 
tissue,  which  is  not  true  of  fibroma  in  any  form. 

Treatment. — The  principal  hope  lies  in  surgical  interference,  and, 
fortunately,  this  can  often  be  successfully  offered.  Before  resorting  to 
the  knife  it  might  be  well  to  try  the  effect  of  the  galvanic  current, 
using  galvano-puncture  and  very  powerful  currents,  from  fifty  to  one 
hundred  milliamperes.  Some  successful  cases  have  been  reported. 
The  treatment  must  be  kept  up  for  a  long  time — one  or  two  years. 
The  most  certain  results  have  been  obtained  by  amputating  the 
diseased  mass.  This  does  not  seem  to  be  either  a  very  difficult  or 
dangerous  operation,^  and  is  to  be  conducted  on  general  surgical 
principles. 

Fibroma  diffusum. — The  disease  which  I  wish  to  describe  under 
this  head  has  been  usually  described  either  as  elephantiasis,  syphilis, 
or  lupus.    Although  it  resembles  all  these  affections  in  the  hypertrophy 

1  See  p.  528. 


Plate  I 


.ui.ns    nyi-LMli-ophions  (ihintTan).   Moi-.-   pi-opr.i-ly    !•.!..  <n,,i.   DiCl'usiini 

To  rai;o  page   527. 


m:\\'  <;i:()]vtus  of  riii:  vri.VA.  027 

of  tissiu',  thciv  is  ccrdiiiily  a  (li>tiii<'t  ctioloiiical  (litlri-cncc,  :is  well  as  a 
dillert'iicc  in  clinical   hcliavioi-. 

Ktiolo(j}i. — Tlic  cause  is  very  ohsciirc.  Syphilis  has  hccii  more  j:eii- 
erally  assii;iie(l  as  a  cause  than  anythiiij;-  else,  hut  its  i-elatioiis  to  the 
ail'eetion  are  very  uneertaiii.  In  two  cases  seen  by  the  writer,  venereal 
disease  was  admitted,  hnt  iVuni  the  i)atient's  descrij)tion,  as  well  as 
from  the  absence  of"  other  marks  of  syphilis,  the  disease  was  most  ])i'ol)- 
ably  ot"  a  chancroidal  character.  In  cases  reported  by  others  there  has 
sometimes  been  a  distinct  syphilitic  hist(»i'y,  but  this  is  not  universal  ; 
and,  even  iirantino-  it,  the  relation  of  cause  and  elfect  is  still  unprove(l. 
Dr.  ^latthcws  Duncan'  describes  a  disease  as  lupus  which  froiu  the 
plates,  as  well  as  from  his  descriptions,  corresponds  with  the  di.sease 
under  consideration.  He  reports  a  nund)er  of  cases,  but  Dr.  Thin,  who 
examined  his  specimens  mioroseopieally,  declares  that  they  contained 
no  histological  elements  which  would  characterize  them  as  either  lupus, 
gummata,  cancer,  or  elephantiasis.  In  the  same  discussion  ]Mr.  Hutch- 
inson was  inclined  to  regard  the  cases  as  being  syphilitic  in  character, 
but  Dr.  Galabin  reported  that  he  had  found  in  similar  eases  that, 
although  there  might  be  some  evidence  of  syphilis,  the  disease  did 
not  yield  to  autisyphilitic  treatment  alone,  but  was  cured  by  excision 
followed  by  these  remedies.  Paget,  Kaposi,  and  Vidal  are  quoted  by 
Duncan  as  being  opposed  to  the  syphilitic  origin.  Virehow  has  sug- 
gested that  the  destruction  of  the  inguinal  glands  by  obstructing  the 
flow  of  lymph  might  result  in  a  lymphatic  oedema  of  the  parts,  with 
dilatation  of  the  lymph-vessels  and  hypertrophy  of  the  connective  tis- 
sue. A  considerable  number  of  cases  have  been  reported  where  this 
has  occurred,  and  a  one-sided  enlargement  has  followed  the  destruction 
of  the  glands  on  the  same  side.  In  the  two  cases  seen  by  the  author 
the  glands  were  destroyed  by  buboes  resulting  from  chancroidal  ulcers. 
INIayer,  however,  states  that  this  condition  is  sometimes  Avanting.  There 
is  no  evidence  obtainable  at  the  present  time  that  any  bacterial  cause 
for  the  disease  has  been  observed. 

With  such  conflictino-  testimonv  we  must  consider  that  the  cause  of 
this  disease  is  unknown,  but  that  the  gro\\'ths  commonly  follow  some 
local  irritation  seems  to  be  probable. 

C/inical  Histoi'i/.—^The  disease  usually  affects  women  during  the 
period  of  sexual  activity.  The  parts  affected  are  the  labia  majora,  the 
clitoris,  and  the  labia  minora,  in  the  order  named.  Often  the  whole 
rima  vulvte  is  affected,  the  groAA-th  forming  a  distinct  collar  around  the 
entrance  to  the  vagina,  which  may  thus  be  nearly  closed  and  the  sexual 
act  be  entirely  prohibited.  The  growths  are  usually  largest  near  the 
clitoris,  becoming  smaller  as  they  approach  the  perineum.  One  side 
alone  may  be  affected,  or  the  whole  supra  vulvar  region  be  the  seat  of 

'  Obstet.  Trans. 


528  DISEASES   OF  THE   VULVA. 

the  disease.  The  growths  are  very  irregular,  and  are  broken  up  into 
lobes,  and  often  portions  form  polypoid  tumors  with  distinct  pedicles. 
In  other  cases  the  whole  gro^^i:h  assumes  the  shape  of  a  polypus.  The 
surface  is  usually  smooth,  lobulated,  and  may  be  pink,  nearly  white,  or 
brownish  in  color.  If  covered  by  the  skin,  it  may  be  warty  and  fis- 
sured. Ulceration,  simple  in  form  and  not  typical  of  either  syphilis 
or  lupus,  often  occurs,  especially  between  opposing  surfaces,  from  pres- 
sure and  friction.  Cicatrices  are  frequently  present  from  old  ulcerations. 
Unless  inflamed,  the  growths  are  usually  insensitive  and  painless,  and 
do  not  directly  interfere  with  the  general  health  of  the  patient.  They 
are,  however,  a  hinderance  to  coitus,  and  if  large  to  locomotion,  and  if 
ulcerated  or  inflamed  may  be  very  sensitive  and  painful.  They  grow 
slowly  as  a  rule. 

Pathological  Anatomy. — The  substance  of  the  growths  is  connective 
tissue  in  all  stages  of  development.  Around  the  vessels  and  under  the 
epithelium  will  be  found  more  or  less  small  cell-infiltration.  The  skin 
or  mucous  membrane  is  not  usually  thickened,  as  in  elephantiasis,  nor 
are  the  walls  of  the  lymphatics  or  veins  thickened  and  enlarged.  There 
is  usually  a  distinct  dilatation  of  the  lymphatic  spaces  from  contained 
fluid,  but  without  proliferation  of  the  endothelium. 

Prognosis. — If  left  to  themselves,  these  growths  last  indefinitely, 
growing  slowly  or  remaining  stationary,  but  do  not  kill,  unless  deep 
ulceration  and  sloughing  take  place — a  rare  occurrence. 

Treatment. — The  only  treatment  which  seems  to  oifer  any  chance  of 
success  is  surgical.  In  removing  the  gro^\i:hs  several  methods  are  open  for 
choice,  the  same  methods  being  applicable  to  operations  on  elephantiasis. 
Schroeder  proposed  to  cut  a  small  section  at  a  time  from  below  upward, 
and  to  control  the  hemorrhage  by  bringing  the  parts  together  by  deep 
sutures  before  cutting  farther.  This  is  done  a  short  distance  at  a  time, 
first  on  one  side,  and  then  on  the  other,  until  the  whole  mass  is  removed. 
A  number  of  cases  have  been  successfully  operated  on  by  this  method. 
By  the  use  of  hsemostatic  forceps  in  plenty,  the  whole  mass,  even  if  large, 
might  be  excised  at  once,  and  the  bleeding  points  secured  as  fast  as  cut. 
The  cautery,  either  the  wire  or  the  thermo-cautery,  has  also  been  used, 
and  is  safer  and  prevents  any  serious  loss  of  blood.  In  one  case  the 
writer  followed  two  plans — cutting  and  suturing  on  one  side  and  cauter- 
izing on  the  other.  The  result  was  the  same  on  each  side,  as  the  cut 
side  did  not  unite  by  primary  union,  but  both  healed  by  granulation. 
So  low  is  the  vitality  of  the  parts  that  primary  union  cannot  be  con- 
fidently expected.  A  good  result  may  be  obtained  by  the  method  pro- 
posed by  Munde,  who  safely  removed  a  large  tumor  by  passing  three 
needles  through  the  face  of  the  growth  and  tying  an  elastic  ligature 
around  it.  When  the  elastic  ligature  was  loosened  the  vessels  were  seized 
and  tied  with  silk.     Union  took  place  except  in  the  track  of  the  silk 


\i:\v  aiiowms  or  riii-:  vi'lva.  521) 

liiT'atnns.  ICinnul  liiis  ()|)(i:i(((l  liy  [cissiiiji;  silver  Hiiturcs  cntin-lv 
Ix'liiiitl  the  <^i-(»\vlli,  ami  tlicii  (wistiiiL!  tlicm  as  fast  as  the  incision  was 
uukIc,  tliiis  conti'ollinj;'  the  liciiKinliauic.  SniMllcr  tinnors  have  lu-cn 
remove*!  I'v  the  clastic  li<;atiire  alone,  a  Ciiitdw  hciuf^  cut  anjiiiid  tlic 
lUH'k  of  f.lit'  tumor  tlii-oiiu'li  tin'  skin  or  nuic<)ns  iiienil)rane,  and  the 
li«2,atiire  placed  in  tli<'  liiirow.  This  niij^ht  he  done  in  the  case  of 
polypoid  masses  hy  the  aid  of  cocaine.  The  pos- ihiliiv  of  the  removal 
hv  electrolysis  is  not  to  be  forjj^otten. 

FiHiioMA  AND  l'^iMi{()-MY()MA. — I'^'ihroid  tumors  arc  quite  rare,  as 
distintiiiishcd  iVom  elephantiasis  and  iihroma  diffusum.  They  most 
conunonly  have  their  origin  in  the  connective  tissue  of  the  labia 
niajora,  tIiou<jli  other  parts  of  the  vulva  may  be  their  seat.  They  are 
usually  small,  but  have  been  known  to  grow  to  a  great  size.  When 
large  and  heavy,  they  stretch  the  point  of  origin,  by  dragging  on  it, 
until  they  become  pediculated.  They  are  usually  smooth  and  rounded, 
but  may  be  lobulated  and  irregular.  They  are  com])osed  entirely  of 
connective  tissue,  and  covered  by  a  thin  but  normal  layer  of  skin  or 
mucous  membrane.  The  skin  is  usually  movable,  while  the  mucous 
membrane  is  more  apt  to  be  closely  adherent  to  the  tissue.  In  some 
instances  the  covering  has  been  converted  into  a  dense  capsule. 

There  are  two  varieties,  the  hard  and  soft — the  latter  is  often  called 
fibroma  molluscum — differing  only  in  the  amount  of  fluid  contained  in 
the  meshes  of  the  connective  tissue.  There  may  be  a  greater  or  less 
infiltration  of  round  cells.  The  tumors  often  become  oedematous  during 
menstruation  and  pregnancy.  Ulceration  of  the  surfaces  from  friction 
is  not  uncommon  ;  inflammation  may  result  and  abscesses  be  formed. 
As  a  rule,  they  grow  slowly,  and  in  time  may  attain  a  great  size. 

Myoma. — Tumors  of  this  kind  have  been  occasionally  observed  on 
the  vulva.  They  probably  have  their  origin  in  the  few  smooth  muscle- 
fibres  which  are  the  remains  of  the  round  ligament.  They  differ  in  no 
respect,  except  histologically,  from  fibromata,  and  from  each  other  only 
in  the  relative  amount  of  smooth  muscle-fibre  and  connective  tissue.  Dr. 
Bedford  Fenwick '  has  reported  a  case  of  lipo-myoma  of  the  left  labium. 

Si/mpfoins. — The  symptoms  are  mostly  due  to  the  weight  and  size  of 
the  mass.  Incontinence  of  urine  may  occur  if  the  origin  is  near  the 
meatus,  but  this  is  cured  by  the  removal  of  the  tumors.  They  may 
hinder  coitus  and  become  a  great  source  of  annoyance  in  walking  and 
standing. 

Treatment. — These  tumors  may  be  removed  by  the  ecraseur,  elastic 
ligature,  hot  wire,  knife,  or  scissors.  The  hemorrhage  is  usually  slight 
and  the  cure  complete,  as  there  is  no  tendency  to  return. 

*  Brit.  GyitcECologicalJourn.,  Feb.,  1887,  p.  465. 
Vol.  I.— 34 


530  DISEASES  OF  THE   VULVA. 

Myxoma. — These  tumors  consist  of  a  tissue  which  has  for  its  type 
the  umbilical  cord,  and  are  therefore  soft  and  yielding.  They  contain 
spheroidal,  stellate,  and  fusiform  cells,  often  anastomosing.  The  inter- 
cellular spaces  are  filled  with  a  soft,  gelatinous  basement-substance. 
They  are  generally  mixed  with  fat,  lipo-myxoma,  or  with  fibrillary 
connective  tissue,  fibro-myxoma.  The  tumors  behave  much  like  the 
fibromata,  with  the  soft  variety  of  which  they  may  be  easily  con- 
founded. They  are  usually  benign,  but  sometimes  recur,  and  also 
undergo  sarcomatous  degeneration,  when  of  course  they  become  malig- 
nant.    They  seldom  grow  to  any  great  size,  and  are  very  rare. 

Lipoma  (Fatty  Tumoes). — These  growths  usually  have  their  origin 
in  the  fatty  tissue  of  the  labia  majora,  but  have  been  found  on  the  mons 
Veneris  and  nymphse.  They  behave  much  like  fibroids,  becoming 
pedunculated,  but  grow  rapidly,  and  often  reach  a  great  size.  Emmet 
describes  one  reaching  nearly  to  the  knee,  between  six  and  seven  inches 
long.  •  The  woman  carried  it  in  a  bag  attached  to  her  waist.  Stiegel§ 
removed  one  which  weighed  ten  pounds.  Koch  extirpated  one  entire 
which  reached  the  knees,  the  woman  having  already  cut  oif  the  lower 
half  herself.  Goodell  met  with  such  a  tumor  of  the  left  labium  majus 
reaching  to  the  knees. 

Diagnosis. — The  diagnosis  between  lipoma  and  fibroma  might  ofPer 
some  difficulties,  but  this  would  be  of  no  practical  account,  as  the  treat- 
ment is  the  same  in  each  case.  In  Goodell's  case  fluctuation  seemed  so 
sure  that  he  mistook  it  for  a  cyst.  From  their  rapid  growth  they  have 
also  been  confounded  with  sarcomata. 

Treatment. — These  tumors  can  be  readily  removed  by  separating  the 
pedicle  and  closing  the  wound  with  sutures,  or  by  a  process  of  enuclea- 
tion after  having  cut  through  the  integument. 

Papilloma. — There  are  three  forms  of  gro^vth  found  on  the  vulva 
which  may  be  grouped  under  this  head — viz.  1,  simple  papilloma ;  2, 
pointed  condyloma ;  3,  syphilitic  condyloma.  The  second  and  third 
are  probably  due  to  certain  specific  poisons,  while  the  first  occurs  Avith- 
out  assignable  cause. 

Papilloma  Simplex. — Simple  non-specific  warts  are  a  comparatively 
rare  form  of  groA\i:h  on  the  vulva.  They  are,  however,  occasionally 
met  with.  They  may  be  multiple,  as  in  a  case  described  by  Winckel, 
where  the  whole  vulvar  region  was  covered  with  a  multitude  of  small 
warts,  or  they  may  be  single,  as  large  as  a  pea  or  much  larger.  They 
are  common  on  the  mons,  but  are  also  occasionally  found  on  the  labia 
majora  or  the  nymphse.  I  have  met  wath  a  single  example  in  the  lat- 
ter situation.  The  grov/th  was  low,  broad-based,  about  one  quarter  of 
an  inch  in  diameter,  and  was  on  the  outer  edge  of  the  left  nympha. 


AKW   CllOWTIIS   OF   THr.     VCIA'A.  5;J1 

Thciv  was  IK)  history  <»r  siirn  of  vciicical  (lismsc.  It  rosoinblod  exactly 
similar  iirowths  soiiu'timcs  luimd  on  the  toii<;ii<'.  (jrillcttc'  mot  with  a 
<>;rowth  as  hiruc  as  two  tists  on  tlic  hil)iiim  majiis  ot"  a  \i\v\  nine  years  ot" 
auc  There  was  no  history  of  syphiHs  or  of  any  inllammatorv  affec- 
tion. The  yrowtli  reseml^led  a  sy|)hiHtic  condyloma,  bnt  was  more 
prominent.  Her  sister  liad  a  simihir  atfeeti(jn,  and  died  of  septiea'miu 
followinj!;  its  removah 

JIi.sfolof/i/. — These  jjjrowths  consist  of  an  hypertrophy  of  tlie  j)aj)ilUe 
of  the  skin  or  mneous  membrane,  with  a  eorresi)onding  thicUeninj^  of 
the  epithelial  layer,  and  an  incrca.se  of  connective  tissue  underneath. 
They  arc  sometimes  sessile  or  have  short  i)edieles ;  the  surface  is  not 
dee[)ly  divided  as  in  the  p(jinted  condyhjmata. 

In  this  division  mu.st  also  be  classed  the  so-called  oozing  tumor  of  the 
labia,  first  descri])ed  by  Sir  C.  M.  Clark.  There  is  n(j  puljlished  account, 
which  I  can  find,  of  a  microscopic  examination  of  such  a  growth,  but 
descriptions,  and  a  plate  in  Emmet's  work,  leave  little  doubt  as  to  its 
true  histolotry.  Clark  describes  one  as  growing  on  the  outside  of  the 
labium,  which  corresponds  with  Emmet's  case.  It  was  raised  one-eighth 
to  one-third  of  an  inch  aljove  the  surface,  and  was  lobulated  and  fis- 
sured. Its  peculiarity  is  that  it  discharges  a  great  amount  of  Avatery 
fluid  from  its  surface,  the  amount  varying  with  the  weather  and  state 
of  the  patient.  It  occurs  mostly  in  weak,  fat,  middle-aged  women. 
Such  tumors  are  very  rare,  and  the  name  should  be  dropped,  as  being 
biLsed  on  a  peculiarity  which  is  not  confined  to  these  gro"s\i:hs,  and  which 
is  not  always  present.  More  careful  observation  is  needed  on  the 
subject. 

Treatment. — If  small,  the  g^o^^i:hs  may  be  destroyed  by  applications 
of  acetic  acid,  carbolic  acid,  or  other  caustics.  But,  undoubtedly,  the 
l)est  method,  when  they  are  large  and  not  vciy  numerous,  is  to  remove 
them  Vtith  the  scissors  or  knife  imder  cocaine,  and  then  bring  the  edges 
of  the  M'ound  together  with  fine  sutures.  If  the  gro^iihs  are  quite 
small  and  numerous,  electrolysis  may  be  used ;  but  if  they  are  large 
and  hemorrhage  is  feared,  the  electro-cautery  wire  may  be  used,  as  was 
successfully  done  in  Gillette's  case.  The  so-caUed  oozing  tumors  have 
been  successfully  removed  by  cutting,  and  no  return  noted. 

Pointed  Condyloma  {C  acuminata,  Venereal  Warts,  Specific  Veg- 
etations).— It  is  only  within  comparatively  recent  times  that  the 
true  nature  and  relation  of  these  groA\i:hs  has  been  understood. 
They  may  grow  in  all  portions  of  the  genital  tract,  from  the  cervix 
uteri  to  the  skin  on  the  perineum  and  thighs.  Their  most  common 
seats  are  the  inner  surfiices  of  the  labia  majora,  vestibule,  and  perineum. 
They  are  always  multiple,  but  cases  have  been  seen  where  a  nund^er 
of  groMiihs  occurring  near  together  have  coalesced  into  one  mass  (Hil- 

>  Am.  Journ.  ObsteL,  1S79,  p.  599. 


532  DISEASES   OF  THE   VULVA. 

debrandt),  so  as  to  appear  like  a  single  growth.  They  are  usually 
quite  small,  but  masses  have  been  observed  as  large  as  a  man's  liand.^ 
When  occurring  on  the  skin  or  mucous  surfaces,  not  subjected  to  pres- 
sure and  not  too  near  together,  they  are  found  to  have  a  very  small 
base,  being  polypoid  in  shape.  They  are  covered  with  a  thick  layer 
of  epidermis,  which  gives  them  a  yellowish  or  grayish  appearance,  but 
when  constantly  moist  they  become  semi-transparent,  bearing,  as  Mc- 
Clintock  observes,  a  resemblance  to  the  white  muscular  tissue  of  fish. 
Often  a  number,  springing  from  contiguous  surfaces,  seem  to  present 
a  large,  broad-based  growth,  but  on  careful  examination  will  show  a 
number  of  separated  pedicles,  and  only  an  apparent  coalescence.  On 
the  skin  they  may  be  dry  and  hard,  but  when  springing  from  a  mucous 
surface  and  constantly  bathed  in  moisture,  they  are  soft.  Those  occur- 
ring within  the  vulva  and  vagina  do  not  so  much  tend  to  assume  the 
polypoid  form ;  but  the  relative  smallness  of  the  base  can  always  be 
observed,  and  is  quite  characteristic.  The  surface  of  the  growth  is 
always  divided  into  small  lobules  with  pointed  ends,  when  not  flattened 
by  pressure,  like  a  cock's  comb.  Sometimes  one  pajDilla  will  be  longer 
than  the  others,  giving  a  distinctly  pointed  shape  to  the  whole  growth. 
The  diiferences  in  appearance  and  shape  are  due  only  to  environment. 

If  pregnancy  coexist,  the  course  of  the  disease  is  somewhat  changed. 
The  w^arts  then  grow  to  a  much  greater  size,  and  the  number  is  also 
greatly  increased  :  the  vagina  is  more  likely  to  be  affected.  In  the 
vagina  the  warts  are  usually  smaller  and  more  rounded,  resembling  in 
some  cases  granulations.  They  may  cover  the  whole  vaginal  mucous 
membrane,  and  even  invade  the  cervix,  covering  its  surface,  though 
there  is  no  record  of  their  having  entered  its  cavity.  With  these 
growths  the  discharge  from  the  vagina  is  usually  very  profuse.  It 
is  stated  that  after  labor  the  growths  rapidly  diminish  and  disappear. 
This  observation  we  are  unable  to  corroborate,  never  having  seen  such 
a  result,  and  Winckel  states  that  it  does  not  ahvays  occur.  Whether 
the  groAvths  occur  during  pregnancy  as  a  result  of  the  irritation  of  the 
increased  discharge  at  that  time,  is  unsettled ;  but  in  my  experience  a 
direct  gonorrhoeal  infection  has  ahvays  been  distinctly  traceable.  Given 
the  infection,  the  increased  formative  activity  of  pregnancy  would  be 
enough  to  account  for  their  rapid  growth. 

Etiology. — It  is  all  but  universally  conceded  that  these  growths  are 
due  to  the  poison  of  gonorrhoea.  They  have  incorrectly  been  attrib- 
uted to  syphilis,  but  clearly  have  not  the  slightest  relationship  with 
that  disease,  though  the  two  may  undoubtedly  coexist.  Some  author- 
ities consider  that  other  irritating  discharges,  besides  those  due  to  gon- 
orrhcea,  may  be  the  exciting  cause ;  but  this  is  rendered  much  less  prob- 
able now  that  the  characteristics  of  chronic  gonorrhoea  are  better  under- 

^  Massot,  De  V Influence  des  Traumatismca  sur  les  Grossesse,  Paris,  1873. 


M-nv  (niowTiis  OF  THE  vriA'A.  533 

httxid.  That  (lie  i;iiii(irrli(r:il  pnisoii  may  exist  in  tlic  vagina,  with  an 
aniitunt  i>f  (lis('liar;j;('  so  small  as  to  t'scapc  notice,  is  certain  (latent 
«2;onoiTli(ea  of  \oeu<i'ei'titli) ;  and,  this  being-  the  case,  the  poison  (gei'in) 
max  l>c  I'onnd  in  discharges  chie  primarily  to  cancel-,  inflammation,  or 
other  diseases.  It  is  nearly  certain  that  tiio  presence  of  an  irritating 
<li.-cliarge  withont  the  sju'cific  cause  of  this  disease  is  not  en(»ngh  to 
eanse  the  Iniination  of  the  gntwths.  J'^irther  ex|)ei-imentation  and 
ohservation  is  necessary  to  j)lace  this  among  the  acce]»ted  facts,  hnt 
onongh  has  been  done  to  render  it  all  bnt  settled,  (jrernis,  the  gono- 
c'occi  of  Xeissi'r,  have  been  found  in  the  growths  themselves  and  in 
the  discharges  accompanying  them,  and  efforts  liave  been  made  at 
transplantation  ;  but  the  results  have  been  unsatisfactory  and  have 
proved    nothing. 

lUdohx/ii. — The  warts  consist  of  a  very  delicate  branching  frame- 
work of  connective  tissue,  containing  a  few  relatively  large  l)lood-ves- 
sels,  covered  Avith  a  very  thick  layer  of  epidermis  or  epithelium.  They 
have  not  been  observed  on  surfaces  covered  with  cylindrical  epithelium. 

Trcat}nent. — Undoubtedly,  the  speediest  mode  of  cure  is  to  remove  the 
growths.  This  may  be  done  with  scissors,  knife,  or  caustic.  If  simply 
cut,  a  small  pw'tion  may  be  left,  which  will  be  the  seed  from  which  the 
wart  will  grow  again  ;  but  if  cut  and  the  base  cauterized,  a  certain  cure 
is  arrived  at.  AVlien  they  are  small,  soft,  and  near  together,  the  sharp 
spoon  mav  be  used  with  good  effect,  all  bleeding  points  being  afterAvard 
touched  with  caustic  or  actual  cautery.  Numerous  applications  have 
been  advised  which  have  for  their  object  the  drying  up  and  gradual 
(h^struction  of  the  growths.  Among  these  may  be  mentioned  concen- 
trated carbolic  acid,  chromic  acid  (gr.  c-5J),  Fowler's  solution.  Solu- 
tions of  corrosive  sublimate  in  alcohol,  and  corrosive  sublimate  and 
collodion  (1  : 8),  have  been  highly  praised.  Glacial  acetic  acid  is 
very  effective,  and  lastly  the  tincture  of  Thuya  occidentalis.  This  is 
asserted  to  have  a  specific  effect.  The  parts  are  to  be  kept  constantly 
moistened  with  it.  It  will  be  noticed  that  all  these  agents  are  para- 
siticides. 

In  the  pregnant  state,  if  we  accept  the  specific  theory  of  causation, 
it  is  certainly  very  necessary  that  the  disease  should  be  cured  before 
labor  comes  on.  If  the  gonorrhoeal  poison  is  left  in  the  vagina,  there 
is  danger  of  its  extension  during  the  puerperium,  and  also  great  danger 
of  ophthalmia  for  the  newborn  child.  It  is,  however,  impossible  to 
cure  the  gonorrhoea  as  long  as  the  warts  are  left.  The  first  step,  then, 
is  to  remove  them,  both  from  the  vulva  and  from  the  vagina.  In  a 
considerable  number  of  cases  the  writer  h;\.s  done  this  at  various  stages 
of  pregnancy  in  the  following  manner  :  The  patient  being  etherized,  the 
external  warts  were  cut  or  scraped  off,  and  their  bases  touched  with  a 
point  of  silver  nitrate  or  red-hot  cautery,  thus  controlling  all  hemor- 


534  DISEASES  OF  THE   VULVA. 

rhao-e.  In  the  vagina  the  growths  were  removed  with  the  finger-nail 
or  sharp  spoon.  A  very  large  cylindrical  speculum  was  then  intro- 
duced, and  after  all  blood-clots  and  discharges  had  been  carefully 
removed,  an  ounce  of  a  solution  of  silver  nitrate  (3J  to  |j)  was  poured 
in  and  the  whole  surface  mopped  over  as  the  speculum  was  gradually 
withdrawn.  This  application  was  repeated  once  in  three  days  until 
all  discharge  had  ceased.  Any  remaining  fragments  of  warts  found 
outside  were  treated  with  glacial  acetic  acid.  If  the  urethra  and  other 
passages  were  infected,  they  too  were  treated,  as  they  might  be  a  lurk- 
ing-place for  the  poison  and  the  source  of  a  new  infection.  This  method 
will  be  found  very  eifective,  and  in  no  instance  has  the  course  of  gesta- 
tion been  interrupted  or  hemorrhage  at  all  severe. 

Very  large  growths  or  masses  may  be  removed  by  the  galvano- 
cautery  wire.  It  is  to  be  remembered,  in  all  cases,  that  the  mere 
removal  of  the  warts  without  curing  the  specific  discharge  will  have 
only  a  temporary  effect. 

Syphilitie  condyloma,  or  mucous  patches,  are  commonly  found  around 
the  vulva  and  vagina.  They  are  flat,  broad-based,  and  sometimes  coa- 
lesce, involving  large  surfaces.  They  are  generally  soft  or  spongy,  and 
are  covered  with  a  grayish  secretion  like  mucus,  which  is  said  to  con- 
sist of  softened  and  broken-down  epidermic  scales.  They  have  no  pedi- 
cles, but  are  broadest  at  their  bases.  They  are  stated  (Duhring)  "  to 
sometimes  take  on  action  which  results  in  the  formation  of  luxuriant, 
hypertrophic,  warty,  papillary  growths,"  when  they  are  easily  con- 
founded with  the  venereal  wart.  Local  antisyphilitic  treatment  soon 
causes  them  to  disappear. 

Cystoma. — Cystic  groAvths  are  not  very  uncommonly  met  with  in 
the  vulva.  The  majority  undoubtedly  have  their  origin  in  the  vulvo- 
vaginal gland ;  but  besides  these  there  are  cysts  which  possibly  exist 
as  retention-cysts  in  Gartner's  canal,  and  others  which  have  their  origin 
in  the  capsule  formed  around  old  blood-clots.  Another  origin  may  be 
found  in  the  enlarged  lymphatic  spaces  (Klob).  Besides  these,  dermoid 
cysts  have  been  observed,^  but  are  extremely  rare. 

Cysts  of  the  Vulvo-vaginal  gland  are  true  retention-cysts,  and  arise 
from  an  obstruction  in  the  duct  of  the  gland,  or  from  a  stoppage  of  the 
duct  leading  from  a  single  acinus.  They  are  found  in  the  labia 
majora  in  the  region  of  the  gland,  and  are  usually  round,  smooth  cysts 
of  varying  size,  but  never  reach  any  great  magnitude.  One  observed 
by  the  writer  reached  the  size  of  an  egg  in  seventeen  years.  When  the 
whole  gland  is  involved  they  may  be  lobulated,  corresponding  to  the 
structure  of  the  gland. 

Cysts  found  in  the  upper  part  of  the  vulva  near  the  meatus,  and 
^  Kirmisson,  An.  de  Gyn.,  1874,  p.  148. 


MJW   (UIOWTIIS   OF   Till-:    VIJIA'A.  O.-Jo 

sometimes  exteiuliii;:;  up  tlu>  anterior  va<;inal  wall,  air  tlioii<:lit  to  have 
their  ori;;in  in  (Jartiicr's  canal,  a  lietal  sti-iictiirc  nsiially  ohliicralcd, 
Tlie  othei"  i'oiMiis  ofcyst  may  l)c  iuiind  in  any  |i,iri  dl'tlic  vuKa,  and  are 
sometimes  veiy  (leej\  extending;'  intu  the  |)clvi>,  uv  arc  lirnd\-  attached 
to  till'  hitne. 

W'cn-likc  tnniors  I'onncd  iVoin  the  oecliisioii  of  sebaceous  {rJand.-  have 
been  reported. 

In  a  ease  recently  hroiiLiht  to  inc  hy  Dr.  \\'.  M.  Hakcr  (»l'  Warren, 
Pa.,  a  eyst  ot"  the  left  hiMnin  majus,  nearly  llmr  inches  long,  jjrnjectintr 
in  such  a  way  as  to  »;reatly  resemble  a  ])enis,  was  c(»nnected  throutih  the 
iniiuinal  eanal  witii  a  cyst  ot"  the  abdomen  reachinji'  two-thirds  of  the 
^vay  to  the  und)ilieus.  The  contents  was  a  thin,  watery  fhiid  with  a 
good  many  pus-eells.  The  cyst  broke  in  the  labium  and  emptied  itself 
entirely.  I  am  not  sure  as  to  the  nature  of  the  eyst,  but  think  it  mav 
be  a  hydrocele  of  the  round  ligament,  which  extended  abo\'e  the  internal 
abdominal  ring  and  formed  the  tumor  in  the  abdomen,  as  the  point  of 
least  resistance.  When  the  sac  in  the  vulva  was  open  the  finger  could 
be  passed  through  the  inguinal  canal  into  the  eyst  al)ove. 

The  contents  of  labial  cysts  is  usually  a  clear,  watery  fluid.  Oeea- 
sionally  it  is  dark-brown,  thick,  or  even  purulent.  The  walls  of  the 
sac  are  generally  thin,  but  strong,  and  arc  lined  with  epithelium  and 
firmly  united  with  surrounding  tissues. 

Syiapfoms. — These  cysts  grow  very  slowdy,  and  at  first  cause  no  incon- 
venience ;  but  occasionally  they  get  large  enough  to  interfere  with  coitus 
and  to  cause  discomfort,  and  even  pain,  in  locomotion.  Tliey  may 
become  inflamed  and  suppurate,  but  usually  only  as  the  result  of 
mechanical  violence. 

Dinr/nosis. — Cyst  of  the  vulva  may  be  confounded  with  hydrocele, 
hernia,  abscess  of  the  vulvo-vaginal  gland,  and  hernia  of  the  ovary. 
The  diagnosis  can  generally  be  made  by  the  feel  of  the  tumor,  its  situ- 
ation and  insensitiveness,  and  its  long  and  slow  growth.  If  doubt  be 
felt,  tapping  with  a  hypodermic  needle  is  fully  justifiable,  and  will 
reveal  the  true  nature  of  the  disease. 

Traifment. — We  may  extirpate  the  cyst  by  dissecting  it  carefully  from 
the  surrounding  tissues.  If  the  cyst  be  superficial,  this  is  undoubtedly 
the  most  satisfactory  method  ;  but  if  it  is  very  deep  and  large,  the  ope- 
ration is  likely  to  be  a  difiicult,  if  not  a  severe  one,  as  the  hemorrhage  is 
apt  to  be  consideraable.  Great  care  should  be  taken  daring  the  opera- 
tion not  to  rupture  the  cyst.  After  it  is  removed  the  wound  should 
be  lirought  together  with  deep  sutures,  so  as  to  get  primary  union.  The 
method  of  incising  the  cyst  on  its  mucous  surface,  and  then  destroying 
its  lining  membrane  with  caustic,  Avill  give  good  results;  but  the  heal- 
ing process  is  very  sIoav,  and  the  resulting  scar  quite  large.  .V  lietter 
plan  is  to  pull  up  a  portion  of  the  sac-wall  with  a  tenaculum,  and  cut 


536  DISEASES   OF  THE   VULVA. 

out  a  considerable  portion  with  scissors.  The  interior  of  the  sac  can 
then  be  painted  with  iodine  and  packed  with  gauze.  Withdrawing 
the  fluid  with  an  aspirator,  and  injecting  a  fe^v  drops  of  iodine  or 
carbolic  acid,  will  be  enough  to  cause  an  adhesive  inflammation  and 
destruction  of  the  cyst,  and  is  particularly  applicable  to  small  growths. 

Gaseous  Tumor. — Lusk^  has  described  a  tumor  of  this  kind.  It 
was  an  abscess  of  the  vulvo-vaginal  gland  communicating  with  the 
rectum.     It  is  interesting  from  a  diagnostic  point  of  view. 

Osteoma  and  Enchondroma. — These  tumors  have  so  seldom  been 
seen  that  they  are  simply  surgical  curiosities.  Zweifel  quotes  a  case  from 
Schneevogt  of  enchondroma  of  the  clitoris  as  large  as  the  fist.  He  also 
mentions  Beigel's  case  of  ossification  of  the  clitoris  as  belonging  to  the 
same  category,  as  Avell  as  a  similar  case  mentioned  by  Bartolin. 

Neuroma. — Simpson^  states  that  he  has  found  neuromata  or  small 
nodular  tumors  occurring  under  the  mucous  membrane  around  the 
urethra,  such  as  are  found  under  the  skin  in  other  parts  of  the  body. 
He  advises  their  extirpation,  as  the  only  hope  of  relief.  Jackson^ 
has  described  a  similar  case. 

Kennedy*  describes  certain  "sensitive  papillse  and  warts"  which,  he 
says,  are  exquisitely  painful  and  often  very  small.  They  were  found 
on  the  labia  minora  and  in  the  vestibule,  and  occurred  after  labor,  from 
imperfectly-cured  ulcerations.     He  advises  removal  with  the  scissors. 

Angioma. — Sanger^  reports  a  case  of  congenital  angioma  in  a  child 
ten  weeks  old.  The  right  labium  majus  was  affected.  The  tumor  was 
like  a  cock's  comb,  3  cm.  high,  1.5  cm.  broad,  and  1  cm.  thick.  It 
had  grown  rapidly  since  birth.  Hennig  met  with  a  similar  case  in 
a  child  two  years  old.  Sanger's  case  was  perfectly  cured  by  excision 
and  suture.  Some  fibroids  have  a  more  or  less  angiomatous  structure. 
Thomas  describes  a  disease  affecting  the  urethro-vaginal  tubercle  to 
which  he  gives  the  name  of  "  urethral  venous  angioma."  It  closely 
resembles  irritable  caruncle,  but  is  to  be  distinguished  from  it  by  its 
want  of  sensitiveness. 

Melanoma. — Several  cases  ®  of  this  kind  have  been  reported,  gen- 
erally as  melano-sarcoma.     The  tumor  may  be  extirpated,  but  will  be 

1  Am.  Journ.  Obstet.,  1880,  p.  389.  ^  Works,  1872,  p.  784. 

^  See  article  on  "  Sterility. "  *  Med.  Press  and  Circ,  June  7,  1 874. 

s  Centralbl.  /.  Gyn.,  1882,  p.  175. 

«  H.  Green,  N.  Y.  Journ.  of  Med.,  1844,  ii.  p.  323;  Miiller  (for  Martin),  Berl.  klin. 
Wochenschrifi,  1881,  No.  31 ;  Bull.  Soc.  Anal,  de  Nantes,  1878-79. 


m:w  anoWTUs  of  'iiir:  vilva.  .037 

<|iiit('  llkclv  to  rcliini,  tlioiii;li  Marlin's  m'coikI   case  is  i-cportcd  tu  have 
Ix'cii   niiH'd. 

Saucoma. — Sjircoinn  (»('  tlic  \iilva  is  furtmiatdy  amoii^  tlic  rarest 
forms  (if  new  i;i-o\\lli  round  in  lliis  siliiali(»n.  Wiiickcl  '  reports  Itnt 
2  anion^'  1  ()(>,()( )0  iixiiccolonical  cax's.  (Jiirlt's  statistics  show,  aiiioiiir 
4S;J  easi's  of  sarcoma,  1  of  the  urethra,  .">  of  the  reetutn,  1  of  the 
vainiiia,  <S  of  the  uterus  and  ovary,  150  in  the  lireast,  and  none  in 
the  \nlva.  His  observations  extended  over  twcntv-four  vears,  and 
inehided   11,140  women   with   tumoi's. 

'I'here  are  scarcely  enonuh  eases  recorded  to  enable  us  to  (h-aw  a  dear 
picture  of  the  (hsease.  In  some  instances  it  seems  to  l)e  oi-iuinall\' a 
jH'iHeuhited  tumor  without  nh-eration.  Such  Avas  tlic  ap])caranee  in  a 
case  seen  hy  the  writer.  The  rate  of  j^rowth  is  often  very  slow,  and  the 
tumor  may  he  mistaken  for  a  petliculated  lipoma  (Winckel)  or  fibroma. 
In  other  cases  the  tumor  breaks  down  and  forms  an  nicer,  which  i-apidlv 
<^xtcn<ls  until  the  whole  vulva  may  be  involved  (Hildebrandtj.  There 
is  generally  a  marked  tendency  to  hemorrhage,  which  reduces  the  pa- 
tient very  fast,  even  wlien  the  tumor  is  quite  small.  Soft  and  spongy 
tumors  are  particularly  apt  to  bleed. 

The  varieties  of  sarcoma  which  have  been  met  with  are  the  round 
cell,  spindle  cell,  melanotic,  and  myxo-sarcoma. 

The  prognosis  is  exceedingly  bad,  as  in  every  case  so  far  reported, 
sooner  or  later,  there  has  been  a  return  and  a  fatal  result.  In  the  spin- 
dle-cell variety  early  and  complete  extirpation  might  result  in  a  cure. 

Treatment. — The  only  thing  to  be  done  is  to  at  once  remove  the 
groAvth  as  completely  as  possible,  either  by  the  knife  or  the  cautery. 
The  rules  for  operating  are  the  same  as  for  other  tumors  of  the  vulva. 

Caxcer. — Frerjiienc}/. — Cancerous  disease  in  the  vulva  is  more  fre- 
quent than  sarcoma.  Meyer  places  the  relative  fre(piency  of  tumors 
on  the  sexual  organs  as  follows  :  Uterus  first ;  then  brea.st,  ovaries, 
vagina,  and  vulva,  in  the  order  named.  Gurlt^  found,  among  16,G37 
tumoi-s,  11,140  of  the  sexual  organs;  of  these,  7479  were  cancer,  of 
which  72  only  were  on  the  vulva.  A  large  share  of  all  malignant 
tumors  of  the  vulva  are  epitheliomata. 

Varieties. — AYe  commonly  divide  cancer  into  two  forms — carcinoma 
and  epithelioma.  These  ditfer  somew'hat  in  their  anatomical  structure, 
and  also  in  the  mode  of  growth  as  well  as  in  prognosis. 

EpitheJioma  (cancroid)  is  l>v  far  the  commonest.  The  tumors  are 
ilistinguished  microscopically  by  the  peculiar  arrangement  of  their 
cells.  Besides  containing  cells  which  resemble  the  normal  epithelium 
of  the  ]iart  in  which  thev  oriuinate,  they  also  contain,  in  the  alvivill  of 

'  I'dtltiilof/ir  (I.  ]Vcib.  Sesmdonjanc.  '  Quoted  l>y  Wiiu'kel,  loc.  cit. 


538  DISEASES   OF  THE   VULVA. 

the  connective-tissue  stroma,  or  within  the  lymph-spaces,  numerous 
nests  or  "  epithelial  pearls."  These  nests  consist  of  collections  of  thin, 
dry,  horny  cells  resembling  epidermic  cells,  and  are  often  visible  to  the 
naked  eye,  as  they  are  of  a  yellowish  color.  The  sebaceous  glands  are 
usually  implicated  in  the  general  proliferation,  and  show  under  the 
microscope  masses  made  up  of  their  characteristic  epithelium.  These 
tumors  tend  commonly  to  remain  near  the  surface,  and  to  extend  above 
it  in  the  form  of  papillary  masses,  rather  than  to  infiltrate  the  deeper 
tissues.     The  surface  is  generally  necrosed,  forming  ulcers. 

Seat. — The  most  common  seat  is  a  question  of  dispute,  but  any  por- 
tion of  the  vulva  or  mons  is  liable  to  be  affected ;  the  labia  majora, 
esj)ecially  the  upper  third,  and  less  often  the  clitoris,  being  quite  com- 
monly attacked. 

Clinical  History. — The  growth  begins  usually  with  one  or  more  nod- 
ules, which  are  under  the  skin  or  mucous  membrane,  but  to  which  the 
overlying  tissues  are  firmly  attached.  The  epithelium  over  the  tumor 
is  at  first  generally  thickened,  so  as  sometimes  to  form  a  sort  of  callos- 
ity (Mayer),  though  it  must  not  be  forgotten  that  such  a  thickening  of 
the  epidermis  may  occur  independently  of  epithelioma.  The  nodules 
may  reach  a  considerable  size  and  invade  the  deeper  tissues  before 
ulceration  begins ;  but  sooner  or  later  this  characteristic  sign  shows 
itself.  The  growth  now  extends  in  every  direction,  the  ulcerated  sur- 
face growing  with  it.  jN^ew  papillae  appear  through  the  ulcer,  form- 
ing fungating  masses.  The  usual  tendency  to  decomposition  of  the 
discharges  is  not  so  marked  as  when  the  growth  occurs  within  a  closed 
cavity,  as  the  vagina.  The  disease  remains  as  a  local  affection  for  a 
comparatively  long  time,  though  portions  lying  against  the  diseased 
surface  may  be  infected  (Zweifel).  Enlargement  of  the  inguinal 
glands  on  the  affected  side  occurs  late  in  the  disease.  In  the  begin- 
ning the  growth  attracts  but  little  attention  :  there  may  be  some  burn- 
ing and  itching,  or  difficulty  or  pain  in  micturition,  and  the  patient 
may  discover  it  only  by  accident,  when  scratching  or  washing  her- 
self. After  ulceration  has  set  in  the  course  of  the  disease  is  more 
rapid,  and  death  follows  usually  within  two  years  (Zweifel).  Pain 
may  be  entirely  absent  through  the  whole  course,  or  it  may  be  one  of 
the  most  prominent  symptoms.  Death  occurs  from  exhaustion  due  to 
septic  infection ;  severe  hemorrhages  are  rare. 

Cause. — Of  this  we  know  nothing.  The  age  of  the  patient  seems  to 
have  a  predisposing  influence.  The  larger  number  of  cases  occur 
between  the  fiftieth  and  sixtieth  years,  and  about  an  equal  number 
in  each  of  the  decades  immediately  preceding  and  following.  Local 
irritation,  as  from  a  fall,  a  blow,  or  long-continued  itching,  has  been 
assigned  as  a  cause. 

Diagnosis. — The  diseases  most  likely  to  be  confounded  with  epithe- 


A7;H'   alinWrilS   OF    Tin:    177.  IM.  'ilW) 

lloiici  arc  lupus  ami  s\|iliilis.  'I'lic  history  of"  tlic  ••asc  will,  liowcvcr, 
ciiaMc  us  to  (listin^uisli  iM-twccu  tliciu  iti  almost  every  iu-tauee. 
S\|iliilis  will  lia\'e  liceii  preceded  hy  oilier  iiiaiiire>talion>  of  the 
(lisea>e  ;  whih'  the  lonjx  ehroiiie  eouix-  ol'  lu|»us,  the  ahsciU'c  ol"  paiu, 
the  eieatrization  eoiueident  with  uh-eratiou,  the  ahseuee  ol'  the  <'ha- 
raeteristie  watei'v,  t'oul  disehariic,  and  the  ticiieral  j^ood  health  ol"  the 
patient  will  serve  to  (list iiiifiiish  that  alleetion.  In  epithelioma  the 
ulei'r  s|)rea(ls  ra|)idly  ;  the  vihj;v>  are  hard  ami  livid  ;  the  base  is  sof'tei- 
than  the  edo-es ;  and  the  surfliee  is  covered  by  dirty,  hroken-dowu 
tissue,  throUL:;h  which  projections  and  papilhe  <•!'  newly-t'ormed  ti>sue 
luav  apjH'ar.  There  is  no  teiuleney  to  cicatrization  ;  later  on  the  inirui- 
nal  irhiiids  become  atfectetl,  M'hich  is  not  the  case  in  lupus,  while  in 
sy[)hilis  the  enlarixement  occurs  very  early  or  even  antedates  the  ulcer- 
ation. It" doubt  exist,  a  microscopic  examination  of"  a  small  piece  will 
settle  the  ([uestion. 

P/w/((o.v/".s. — The  pro<i;nosis  is  hopeless  unless  the  tumor  is  completely 
removed  at  a  very  early  stage.  The  course  of  this  affection  is  chronic, 
ruiHiing  as  long  as  two  or  three  years ;  sometimes  it  is  mucli  more  rapid. 
Recurrence  after  removal  may  be  delayed  for  a  number  of  years  or  may 
never  happen.  If  the  whole  disease  is  not  removed  at  the  time  of  ope- 
ration, it  returns  at  an  early  date. 

Treafmcnf. — There  is  but  one  plan  which  offers  any  hope  of  cure, 
and  that  is  complete  and  early  removal.  This  may  be  done  by  caus- 
tic, actual  cautery,  or  the  knife.  The  elastic  ligature  has  also  been 
proposed.  The  knife,  followed  or  not  as  the  case  may  be  by  further 
destruction  of  tissue,  offers  the  best  chance.  The  application  of  the 
thermo-cautery  to  a  large  ulcerating  surface  has  in  my  hands  only 
been  followed  by  an  increase  of  pain  and  a  more  rapid  growth  of  the 
tumor.  It  is  impossible  to  thoroughly  destroy  the  growth  in  this  way. 
If  so  situated  that  the  knife  cannot  be  used,  a  caustic  paste  would  seem 
to  offer  the  best  chance  of  deeply  destroying  the  mass.  AVhen  the 
inguinal  glands  are  involved,  Kustner^  advocates  their  removal,  even 
opening  the  ligamenta  lata  and  dissecting  out  all  the  diseased  structures. 
If  the  primary  affection  can  be  entirely  eradicated,  thus  giving  hopes 
of  a  cure,  it  would  seem  decidedly  best  to  follow  his  suggestion  ;  but  as 
the  enlargement  of  the  glands  usually  takes  place  late  in  the  disease, 
when  the  chances  of  entire  removal  are  small,  the  adoption  of  this  jdan 
will  not  often  be  likely  to  be  followed  by  benefit.  It  adds  to  the  diHi- 
culties,  but  not  much  to  the  danger,  of  the  operation. 

Carcinoma. — Under  this  head  we  have  two  forms — medidlarv  or 
soft  cancer,  and  scirrhus  or  hard  cancer,  also  called  atrophic  cancer  and 
fibro-carcinoma.  Melanotic  cancer  has  also  been  observal  (Klob  and 
others).     All  of  these  forms  are  very  rare.     They  occur  primarily  on 

^  Zeilsch.j.  GebnrL^.  und  Gyn.,  vol.  vii.,  1881. 


540  DISEASES   OF  THE   VULVA. 

the  labia  majora,  and  with  relative  frequency  on  the  clitoris,  and  gener- 
ally in  women  upward  of  sixty  years  of  age. 

In  true  cancer  the  epithelial  cells  fail  of  any  special  characteristic 
shape,  but  may  be  of  all  sorts  of  irregular  forms.  The  cells  are  packed 
too-ether  irregularly  in  follicles  or  cavities  in  the  midst  of  a  connective- 
tissue  stroma.  It  is  the  relative  amount  of  connective  tissue  which 
makes  a  hard  or  soft  cancer.  It  begins  deeper  in  the  tissues  than 
cancroid,  and  extends  widely  and  deeply  before  breaking  down.  It 
always  forms  projecting  masses.  The  ulcers  are  covered  with  foul 
discharo;e  and  broken-down  tissue.  There  is  considerable  tendency  to 
hemorrhage,  especially  in  the  soft  variety,  and  pain  is  usually  much 
more  severe  than  in  epithelioma. 

The  prognosis  is  eminently  unfavorable.  Hildebrandt  stated  that  he 
was  able  to  operate  in  two  cases  at  a  very  early  stage,  but  without  suc- 
cess. The  disease  returned  in  the  scar.  The  lymphatic  glands  are 
affected  easily.  Still,  if  seen  in  the  beginning,  an  operation  for  the 
complete  reinoval  is  not  only  justifiable,  but  imperatively  demanded. 


THE  INFLAMMATORY  AFFECTIONS  OF  THE 

UTERUS. 

Bv  C'lIAUNCEV    1).    I»AI..MK11.  M.  I)., 

ClXClNXATI,    (J. 


Acute  Endometritis. 

Definition  and  Synonyms. — Acute  endometritis  sifinifie.s  an  acute 
inflamniation  of  the  mucous  liuinii;  of  the  uterus  (endometrium).  It 
has  been  called  acute  uterine  leucorrhoea,  or  catarrh,  and  acute  inter- 
nal metritis. 

Pathological  Anatomy. — There  is  a  turgescenee  of  the  vessels 
of  the  nuicous  membrane,  with  infiltration  of  serum,  and  even  lymph- 
cells,  within  its  tissues,  consequent  oedema  and  softening.  Accompany- 
ing these  there  is  more  or  less  catarrh  of  the  mucous  surfaces,  possess- 
ing features  of  the  secretion  of  (a)  the  cervical  canal,  which  at  first  is 
transparent  and  vitreous,  afterward  turbid  and  muco-purulent ;  (6)  of 
the  cavity  of  the  uterine  body,  which  is  thinner,  more  serous,  then  pur- 
ulent, and  often  streaked  with  blood.  An  abundant  formation  and 
desquamation  of  epithelial  cells,  exfoliated  pieces  of  mucous  mem- 
brane, casts  of  utricular  glands,  with  an  escape  from  the  vessels  of 
lyni])h-cells  and  a  few  red  blood-corpuscles,  characterize  the  morpho- 
logical elements  of  the  catarrhal  fluid.  According  to  Scanzoni,  the 
surface  is  often,  at  portions  corresponding  to  the  openings  of  the  utric- 
ular glands,  covered  with  bright  red  spots  encom])assed  by  a  network 
of  deeply-injected  capillaries.  In  severer  cases  the  submucous  layers 
of  the  parenchyma  become  hyperremic,  softened,  and  pul]iy.  The  os  ex- 
ternum l)ecomcs  tumid,  the  labia  ]^utfv,  de]irived  of  epithelium,  and  pre- 
sent the  appearance  of  erosion.     The  uterine  cavity  is  increased  in  size. 

The  best  opportunities  for  studying  acute  endometritis  in  the  dead- 
house  occur  in  fatal  cases  of  the  acute  exanthemata.  The  extent  of 
the  surface  involved  varies  considerably  in  different  cases,  and  is  nuich 
modified  by  the  causative  influence. 

The  disease  maybe  limited  to  the  cavity  of  the  cervix  and  the  ri'ginn 
of  the  OS  externum,  to  the  cavity  of  the  body,  or  it  may  extend  through- 
out the  whole  uterine  canal. 

541 


542       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

Frequency. — Concerning  this  point  there  is  a  wide  difference  of 
opinion  among  prominent  authorities.  By  some,  Klob,  Thomas, 
Priestley,  Edis,  and  Barnes,  it  is  regarded  as  a  frequent  affection.  By 
others,  Schroeder  and  Byford,  it  is  thought  to  be  rare.  Without  doubt, 
it  is  not  found  prior  to  puberty,  and  probably  the  corporeal  mucous 
membrane  is  more  often  attacked  than  the  cervical.  When  we  con- 
sider the  accessibility  of  the  endometrium  to  external  agencies  and 
injuries,  not  only  in  parturition  and  in  the  lying-in,  but  also  in  the  non- 
gravid  state,  the  liability  to  the  upward  extension  of  specific  inflam- 
mation of  the  vagina,  together  with  the  special  physiological  vascularity 
of  its  tissues,  oft  recurring,  it  would  seem  a  matter  of  surprise  that  any 
one  could  doubt  the  frequent  occurrence  of  endometritis  as  an  acute 
affection.  There  is  every  reason  to  believe  that  the  disease  is  often 
overlooked  until  it  has  subsided  into  the  chronic  stage. 

Etiology.-^1.  Traumatic  Causes. — Under  this  head  are  included 
direct  injuries  to  the  uterus  by  excessive  coitus,  the  use  of  sounds,  tents, 
intra-uterine  pessaries,  the  operation  of  incision  of  the  cervix,  removal 
of  intra-uterine  growths,  the  use  of  the  curette,  and  intra-uterine  injec- 
tions. Carelessness  in  the  use  of  vaginal  injections  may  likewise  be  so 
classified. 

2.  Certain  chemicals,  as  caustics,  the  local  action  of  which  is  violent ; 
for  instance,  the  introduction  of  a  crayon  of  pure  nitrate  of  silver  within 
the  uterine  cavity  is  liable  to  excite  inflammatory  mischief  of  the  endo- 
metrium. 

3.  Extension  of  gonorrhoeal  inflammation  from  the  vulva  and  vagina 
may  be  ranked  as  among  the  most  frequent  and  serious  of  causes.  This 
form  of  the  disease  is  too  frequently  not  limited  to  this  territory,  but 
extends  farther,  through  the  Fallopian  tubes  and  to  the  pelvic  peri- 
toneum, producing  what  M.  Bernutz  so  aptly  called  "  female  orchitis." 
Vaginitis  of  a  non-specific  character  does  not  possess  this  tendency  to 
extension. 

4.  Sudden  suppression  of  the  menstrual  flux  from  cold  or  mental 
excitement. 

5.  The  progress  of  the  exanthematous  fevers,  rubeola,  scarlatina, 
variola,  also  of  typhoid  fever,  cholera,  and  phosphorus-poisoning, 
sometimes  so  operates.  Kiwisch  has  spoken  of  "  metastatic  constitu- 
tional catarrh,"  referring  to  this  class  of  cases. 

6.  The  introduction  of  putrid  materials  from  without,  as  well  as  the 
decomposition  of  substances,  solid  and  fluid,  within  the  uterus,  as  the 
products  of  conception,  remains  of  tumors,  retained  menstrual  fluid, 
etc.,  is  an  active  exciting  cause. 

In  the  puerperal  form  of  the  disease  the. origin  of  the  mischief  is 
probably  the  placental  site.  Aside  from  the  local  injury  by  contusion 
and  laceration  received  in  parturition,  the  septic  factor,  whether  auto- 


ACVTK  i-:si)<)Mi:'ri:rris.  rj4;j 

JJOnctic  nr   llctCl'Oii'CIU'tii',  is   llic   mo.-l    illl|iiil-|;ili|.        Aclilc    |il|(|'|i(r;il   cinlii- 

m('trili->  i--  iisiuilly  septic  in  clini.-utcr. 

A  slii(l\'  (tf  (he  ctioliiLty  iiiakv's  it  clc.-ii'  tli;it  in  inu-t  in~t;nic('s  tin- 
intl;innn;itnrv  iictioii  is  lU'ct'ssai'ily  extended  t  liroiiLilinnt  tlie  (ii'iian. 
Acute   enduiiK'tiMtis    is,  as   a    I'lllc,  li-eiXTal. 

SvM  !•  I'.  )MA  It  »i.<  )(i^■. — WHien  arisinii"  from  tranniatic  or  septic  causes 
the  disease  nia\'  l»e  usliered  in  l)\"  a  rii^or,  not  so  proiionnee(|  a>  in  jn'ri- 
iit(>rin(>  inllainniatioiis,  followed  hy  felirile  plieiionieiia.  The  local  symp- 
toms are  pain  ol'  a  didl,  aeliini;'  kind,  willi  dra<i'<:in<;-  seiisiitions  within 
the  pelvis  and  hack;  there  is  tenderness  o\-er  the  hyp()i;astrie  rej^ion  ; 
there  ina\'  he  rectal  and  vesical  tenesmus,  liarely  are  the  symptoms 
of  a  violent  character.  Should  the  vesical  irritation  be  prominent  and 
the  other  symptoms  he  ill  defined,  the  affection  may  be  taken  for  cysti- 
tis. Sudden  attacks  of  diarrhoea  from  reflex  irritation  of  the  n^etal 
nerves  are  occasionally  manifest.  The  diseharg-e  per  vaginam  is  at  first 
slight  and  serous ;  in  a  day  or  two  more  free  and  nnieous ;  then  muco- 
purulent or  purulent,  and  sometimes  bloody.  It  is  offensive  in  septic 
cases,  and  at  times  so  acrid  as  to  occasion  excoriation  of  the  vaginal 
and  vulvar  surfaces,  with  an  aggravating  pruritus. 

PiiYsu'AL  Signs. — On  digital  examination  the  os  will  be  found  to 
be  more  or  less  open,  the  cervix  somewhat  swollen,  the  uterus  tender, 
softened,  and  slightly  enlarged.  Its  position  is  lower  within  the  pelvis. 
Bimanual  exploration  confirms  these  signs.  Tlie  sj^eculum  shows  the 
cervix  swollen,  red  or  livid,  oedematous,  eroded.  If  the  inflammation 
is  confined  to  the  upper  cavity,  no  special  change  in  the  cervix  is  notice- 
able, save  perhaps  a  slight  alteration  in  the  color  of  its  mucous  mem- 
brane. In  all  cases  the  characteristic  discharges  will  be  seen  pouring 
from  the  cervical  canal. 

The  above  signs  having  been  detected,  the  probe  or  sound  ought  not 
to  be  emploved,  for  its  introduction  is  attended  with  pain  and  an  aggra- 
vation of  the  existing  disease.  Nor  should  the  speculum  even  be  intro- 
duced if  the  digital  examination  detects  pronounced  tenderness  of  the 
uterus. 

Diagnosis. — Acute  endometritis  is  to  be  differentiated  from  acute 
vaginitis,  pelvic  cellulitis,  ])elvic  peritonitis,  and  metritis  proper.  Any 
or  all  of  tliese  may  complicate  it.  From  the  first  it  is  easily  diagnosti- 
cated by  a  greater  general  disturbance  and  pain,  a  different  location  of 
tenderness,  the  character  of  the  discharge,  and  the  presence  of  the  signs 
referred  to. 

Pelvic  cellulitis  and  peritonitis  are  each  more  frequently  ushered  in 
Avith  a  rigor,  f  )ll()wed  by  a  higher  temperature,  greater  constitutional 
disturbance,  together  with  more  severe  loe:d  pain  and  tenderness.  Be- 
sides, in  these  two  jieriutcriue  inflammations  the  presence  of  infiltrations 
around  the  cervix  above  the  vaginal  vault,  a  consequent  displacement 


544       THE  I^^FLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

and  diminished  mobility  of  the  uterus,  are  changes  which  in  a  few  days 
are  so  well  defined  that  clearness  in  diagnosis  is  established.  Both  of 
these  affections  uncomplicated  are  unaccompanied  with  any  special 
uterine  catarrh,  though  menorrhagia  or  metrorrhagia  is  a  frequent 
attendant. 

The  diagnosis  between  acute  endometritis  and  metritis  proper  will  be 
referred  to  hereafter. 

PeoGi^OSIS. — Acute  endometritis  is,  ordinarily,  not  an  affection  dan- 
gerous to  life.  Mild  cases  are  recovered  from,  the  existence  of  which 
has  hardly  been  suspected.  Prognosis  is  most  grave  in  the  septic  and 
traumatic  varieties,  the  unfavorable  elements  being  the  supervention  of 
general  septicaemia  and  the  extension  of  the  inflammation  through  the 
Fallopian  tubes  to  the  pelvic  and  general  peritoneum.  When  gonorrhoea 
enters  into  the  causation  the  disease  is  exceedingly  prone  to  this  exten- 
sion and  indefinite  continuance. 

A  sound  constitution,  free  from  diathesis,  favors  a  speedy  recovery. 
As  the  uterine  mucous  membrane  is  quickly  degenerated,  so  with  favor- 
able general  health  it  is  actively  regenerated.  Therefore,  the  most 
unfavorable  aspect  of  acute  endometritis  is  the  marked  tendency  in 
many  constitutions  for  it  to  become  a  chronic  disease. 

A  strumous,  tubercular,  or  syphilitic  diathesis,  a  condition  of  ansemia 
or  impaired  general  health  at  the  time  of  the  inception  of  the  disease, 
favor  its  perpetuation.  Recovery  is  often  only  partial  when  it  is  sup- 
jDOsed  to  be  complete.  Successive  menstrual  approaches  tend  to  rekindle 
the  symptoms.  We  can  be  certain  of  the  accomplishment  of  a  cure  only 
when  one  or  two  such  periods  have  been  passed  without  relapses. 

Treatmext. — The  first  and  most  important  indication  of  treat- 
ment is  rest.  In  the  recumbent  posture  the  affected  organ  is  placed 
at  rest,  pain  is  mitigated,  and  the  pelvic  circulation  favorably  modi- 
fied. The  suggestion  of  rest  becomes  unnecessary  in  severe  cases, 
but  in  the  milder  forms  of  the  disease,  when  the  patients  are  going 
about  or  on  their  feet,  the  injunction  is  imperative.  Rest  is  to  be  main- 
tained so  long  as  there  are  pelvic  pain  and  uterine  tenderness.  Precau- 
tion is  essential  at  the  approach  and  during  the  first  and  second  suc- 
ceeding menstrual  epochs.  Rest  and  the  absence  of  pain  are  likewise 
secured  by  the  administration  of  opium  in  some  of  its  forms.  For  this 
purpose  a  very  desirable  channel  for  medication  is  the  rectum.  Ordi- 
narily, in  this  way  it  requires  a  quantity  of  the  drug  slightly  in  excess 
of  the  dose  by  the  stomach  to  obtain  the  desired  effect.  A  suppository 
of  morphina  sulphate  (gr.  |— ^)  is  to  be  introduced  every  few  hours  if 
pain  is  present.  The  rectum  should  be  unloaded  of  any  fecal  accumu- 
lation by  an  enema  or  a  mild  saline  cathartic.  Active  purgation  is 
ahvays  to  be  avoided. 

The  febrile  movement  is  controlled  by  the  above-mentioned  means 


Arm:  j:.\i)')Mi:ii:rns.  oi.j 

ami  the  iiitonml  adiniiiistratioii  of  tlu-  tiiictun"  of  ac<»nitc'  or  vcratriim. 
Norwoixl's  tiiictiirc  of  vci'ati'iiiii  vii-idc  in  small  doses  is  a  valuable 
a>'eiit  to  re<:;iilate  llic  (irciilatioii  and  Hin-ilc  -yinptonis  in  all  the 
aeiite  nelvie  iiiMaiuiiiati(tiis.  Its  use  is  euntraindicatcil  <Mdy  in  cas*.'?: 
of  marked  asthenia  or  al'ter  septic  absorption. 

The  diet  should  be  easy  of  digestion  l>ut  supporting;  concent rate<l 
foods,  as  beef-juice  and   milk,  are  the  best. 

The  local  abstraction  of  blood  by  leeches  or  otherwise,  the  u.-c  of 
mercurials  in  anv  stage  of  the  disease,  are  not  only  unnecessary,  but 
prejudicial  to  a  speedy  recovery.  Reference,  of  course,  is  not  made  to 
those  cases  complicated  with  periuterine  inflammations,  in  which  one  or 
both  of  these  agents  may  be  especially  indicated. 

Fomentations  are  always  grateful  to  the  patient.  There  is  n(^  more 
convenient  or  efficacious  means  of  ap])lying  heat  and  moisture  than  by 
a  hot  flaxseed  poultice,  the  prepared  material  spread  between  thick 
muslin  and  mosquito  netting,  covered  with  ttiled  silk,  the  whole  poul- 
tice large  enough  to  envelop  the  entire  abdomen. 

Vaginal  injections,  with  water  in  large  quantities,  as  h(jt  as  can  be 
borne  (100°-12()°  F.),  projected  against  the  cervix  and  the  surround- 
ing vaginal  vault,  with  the  patient  on  the  back,  the  pelvis  higher  than 
the  shoulders,  the  current  of  water  being  received  into  a  vessel  at  the 
side  of  the  bed  by  means  of  a  rubber  blanket,  keep  the  cervix  and 
vagina  clean,  prevent  secondary  vaginitis  and  vulvar  })ruritus,  and  act 
as  pcjultices  to  the  interior  of  the  pelvis.  These  injections  should  be 
repeated  from  two  to  t\mr  times  a  day.  Beyond  this  n(»  local  treat- 
ment is  required. 

Sept'iG  en<Joiiietrifis,  arising  from  a  retained  ovum,  placenta,  clots  of 
blood,  or  remains  of  disintegrating  tissues,  demands  the  local  employ- 
ment of  antiseptics,  as  carbolic  acid,  boric  acid,  bicMoride  of  mercuiy, 
or  permanganate  of  potash.  The  bichloride  (1  :  2000-8000)  is  the  best 
known  parasiticide.  In  all  eases  with  offensive  discharges  the  injected 
solution  within  the  vagina  should  contain  one  of  these  remedies  ;  and 
in  those  with  symptoms  of  systemic  absoqjtion,  manifest  or  threatened, 
the  same  kind  of  solution,  though  weaker,  is  to  be  carried  within  the 
uterine  cavity.  It  must  be  admitted  that  certain  risks  attend  intra- 
uterine injections,  even  under  the  circumstances  of  a  large  uterus,  a 
patulous  canal,  and  a  free  exit  for  the  fluid.  But  the  risks  are  not 
great.  Compared  with  the  dangers  of  septic  absoqotion,  or  the 
urgency  for  the  removal  and  disinfection  of  septic  matter,  fresh 
invoices  of  which  by  a  continuous  or  intermittent  imbibition  into  the 
vascular  system  are  being  kept  u]),  these  risks  are  very  small  indeed. 
Fortunately,  the  uterus  is  in  a  condition  less  susceptible  to  these  risks 
of  shocks,  retention  of  the  fluid  and  distension  of  the  cavity,  the  pas- 
sage of  the  same  into  the  peritoneal  cavity,  etc.,  when  the  urgency  for 
Vol.  I.— 35 


546        THE  INFLAMMATORY  AFFECTIONS  OF  THE    UTERUS. 

the  employment  of  antiseptic  injections  is  greatest.  Nevertheless,  the 
utmost  precaution  ought  to  be  instituted.  The  fluid  is  to  be  warmed, 
injected  slowly  and  without  force,  and  the  instrument  conveying  the 
current  so  constructed  as  to  permit  a  ready  exit  of  the  stream.  The 
canula  of  the  author  (Fig.  179)  will  be  found  useful.     The  frequency 

Fig.  179. 


Palmer's  Reflex-current  Canula,  for  washing  out  the  uterus. 

(one  to  four  times  per  diem)  of  these  injections  is  determined  by  the 
amount  of  local  sepsis,  together  with  the  general  septicsemic  phe- 
nomena. 

The  general  treatment  also  demands  modification  in  septic  cases. 
Quinina  in  large  doses  (grs.  xx-xxx),  to  reduce  high  temperatures, 
to  antagonize  the  poison  after  its  absorption,  and  to  support  the  vital 
powers,  is  strongly  recommended.  Alcohol,  acting  in  the  same  man- 
ner,, is  of  immense  value.  It  is  to  be  given  in  large  doses  also. 
Quinina  in  tonic  doses  is  always  beneficial  in  the  stage  of  convales- 
cence of  all  varieties  of  acute  endometritis. 


Acute  Metritis. 

Acute  metritis,  or  acute  parenchymatous  metritis,  signifies  an  acute 
inflammation  of  the  fibrous  structure  of  the  uterus.  In  speaking  of 
the  subject  of  acute  endometritis  reference  was  made  to  the  fact  that 
the  uterine  parenchyma  sometimes  becomes  involved  in  the  inflamma- 
tory changes  occurring  in  the  endometrium.  Unquestionably,  these 
changes  in  the  contiguous  layers  always  occur  in  severe  endometritis. 
Likewise,  Avhen  the  serous  envelope  is  afiected  in  acute  pelvic  perito- 
nitis the  inflammation  dips  down  into  the  subperitoneal  parenchyma. 

Frequency. — It  is  a  matter  of  disputation  whether  acute  metritis 
ever  exists  as  an  independent  aflection.  If  we  are  to  accept  the  testi- 
mony of  the  dead-house,  the  only  reliable  witness,  the  question  must 
be  decided  in  the  negative. 

Klob  says  :  "  Inflammation  of  the  substance  of  the  non-gravid  uterus 
seems  to  be  one  of  the  rarest  affections  to  which  this  organ  is  liable.  I 
have  not  met  with  a  single  case  which,  with  any  degree  of  certainty, 
I  could  pronounce  to  be  one  of  genuine  metritis."  Rokitansky  remarks 
that  "in  acute  inflammation  of  this  organ  generally  the  lining  membrane 
of  the  uterus  is  aflfected  primarily,  and  that  this  is  scarcely  ever  the 


ACUTE  METRITIS.  547 

case  with  llic  iitci-Iiir  tissue,  :is  l:ir  :is  can  he  (Iciiionsli'ad'd  1»\-  the  j)atli- 
()I()^•i(■al  aiialoiiiist,  with  tiic  exception  ol"  the  reaction  lolhtw  inj;-  traumatic 
inHiiences,  especially  of  th(!  va«^inal  poi'tion."  Schroe<h'r,  who  contends 
for  its  occnrrcnce,  achnits  that  it  is  a  very  i-are  «lisca.se,  and  always  comph'- 
cated  with  acute  endometritis.  Thomas  no  ioiiticr  devotes  an  independent 
i'hapter  to  the  subject,  a:ul  regards  metritis  merely  as  a  complication  of 
endometritis.  As  this  author  pertinently  remarks,  with  the  light  of 
the  present  state  of  knowledge  acute  ])arenchymat(»us  metritis  should 
be  placed  in  a  subordinate  instead  of  a  j)rominent  j)lace  in  uterine 
pathology.  The  descriptions  of  most  of  the  older  authorities  have 
been  transferred  to  us  as  matter  of  literary  tradition,  and  not  clin- 
icid  research. 

What  Virchow  designated  as  "  diffuse  puerperal  metritis  " — a  puer- 
peral form  of  inflammation  prevailing  when  certain  epidemic  influ- 
ences are  at  work,  possessing  great  resemblances  to  erysipelas  on  the 
surface  of  the  body — is  in  all  probability  endometritic,  and  not 
metritic. 

The  following  propositions,  in  the  light  of  modern  investigations 
post-mortem  and  at  the  bedside,  may  be  deduced  : 

1.  IMost  cases  of  supposed  metritis  are  instances  of  inflammation  of 
the  endometrium  or  the  periuterine  tissues. 

2.  Localized  metritis,  contiguous  to  the  mucous  layer,  is  resultant, 
not  unfrequently,  on  severe  endometritis. 

3.  Parenchymatous  metritis,  complicated  with  and  resultant  on  endo- 
metritis, is  more  frequent  and  extended  in  the  puerperal  than  the  non- 
gravid  organ. 

4.  Pure  and  uncomplicated  parenchymatous  metritis  rarely,  if  ever, 
occurs. 

Pathological  Axatomy. — The  changes  which  are  noticeable  are 
h}'per£emia,  tumefaction,  and  infiltration  with  serum.  The  uterine  \valls 
are  succulent,  sofltened,  and  at  times  ecchymosed.  Small  collections  of 
pus-corpuscles  may  be  found  between  the  muscular  fasciculi  and  in  the 
uterine  veins.  Abscesses  of  any  dimensions  are  extremely  rare  even 
when  puerperal.  A  uterine  abscess  may  perforate,  and,  according  to  its 
situation,  open  into  the  uterine  or  vaginal  cavity,  or  outwardly  into  the 
peritoneal  cavity,  or  if  proper  adhesions  are  formed  into  the  intestines. 
Cases  of  perforating  abscesses  have  been  described  by  Kiwisch,  Scan- 
zoni,  Bird,  Rcinmann,  and  many  others.  These  abscesses  sometimes 
depart  from  their  usual  course,  and  instead  of  evacuating  in  the  sur- 
rounding cavities  the  incarcerated  pus  undergoes  caseous,  fatty,  or  cal- 
careous degeneration,  then  absorption,  or  becomes  enclosed  in  a  cavity 
by  a  growth  of  the  surrounding  connective  tissue. 

Puerperal  metritis  is  frequently  associated  with  lymphangitis  and 
phlebitis  and  their  sequelae.     Sometimes  the  peritoneal  envelope  of  the 


548       THE  INFLAMMATORY  AFFECTIONS  OF  THE    UTERUS. 

uterus  is  covered  with  fibrinous  exudations.  All  the  changes  in  the 
uterine  walls  are  most  marked  nearest  the  mucous  membrane. 

The  disease  may  terminate  (a)  in  resolution  with  absorption  of  the 
exudation  ;  (6)  in  proliferation  of  the  connective  tissue  with  permanent 
enlargement ;  (c)  in  induration  and  atrophy. 

It  is  most  probable  that  the  condition  of  the  uterus  called  superinvo- 
lution,  first  described  by  Simpson,  is  resultant  on  acute  parenchymatous 
metritis  in  the  puerperal  state. 

Etiology. — Acute  metrititis  is  developed  either  as  an  extension  of 
endometritis,  or  it  arises  from  lesions  in  the  puerperal  bed. 

Symptoms  and  Signs. — Though  more  severe,  the  symptoms  are  the 
same  as  in  acute  endometritis,  with  which  it  is  probably  always  asso- 
ciated. To  touch  and  bimanual  examination  the  uterine  body,  espe- 
cially in  its  antero-posterior  diameter,  is  much  enlarged,  somewhat 
doughy,  and  very  tender. 

Diagnosis. — The  marked  enlargement  and  sensitiveness  of  the  uterus 
are  the  reliable  local  evidences.  They  are  associated  with  the  general 
febrile  phenomena.  Small  collections  of  pus  cannot  be  recognized. 
Larger  accumulations  may  be  diagnosticated  by  the  gradual  increase 
in  the  size  of  the  organ,  a  localized  elasticity  of  its  tissues,  if  not  fluc- 
tuation. 

Peognosis. — The  prognosis  is  more  grave  than  in  j^ure  endome- 
tritis. 

Treatment. — The  same  principles  of  treatment  laid  down  for  acute 
endometritis  are  also  applicable  to  acute  metritis. 

Bibliography. 

Baknes,  R.  :  Diseases  of  Women,  2d  ed. 

Berntjtz  and  Goupil:    Diseases   of  Women,  translated  for  New  Sydenham  Soc. 

(1857). 
Byford,  W.  H.  :   Medicine  and  Surgery  Applied  to  Women,  3d  ed. 
Edis,  a.  W.  :  Diseases  of  Women  (1882). 
KiwisCH  :  Klinik  Vortrdge. 

Klob:  Pathological  Anatomy  of  Female  Sexual  Organs. 
Priestley,  W.  O.  :  Reynold^s  System  of  Medicine,  vol.  v. 
BoKiTANSKY :  Pathological  Anatomy. 
vScANZONi :  Diseases  of  Females. 

ScHROEDEK,  C. :  Diseases  of  Female  Sexual  Organs  (Ziemssen's). 
Simpson,  Sir  Jas.  Y.  :   Works  of,  vol.  iii. 
Thomas,  T.  G.:  Diseases  of  Women,  5th  ed.  (1880). 


Chronic  Endometritis. 
As  does  acute,  so  chronic  inflammation  also  may  attack  the  diiferent 
tissues  and  parts  of  the  uterus.     While  acute  inflammation  is  noted  for 
the  suddenness  of  its  inception,  the  rapidity  of  its  progress,  and  its  com- 


ciiRoxrc  CKiiVicAL  j:.\iK)Mi:Ti:fTis.  549 

parativcly  sluirt  duration,  cliivtiiic  iiillaniiiialioiis,  on  the  (ttlicr  hand, 
aiv  inaniUstcd  l>y  tlicir  insidious  infcption,  slow  progress,  lon^-  dura- 
tion, ami   coiiiparatixcly    mild   s\  niplonis. 

DKKiN'rnoN  AM)  SY^■()^"^■Ms. — ('ln-onic  cndoinctriti.s  sijrnilics  ;i 
clironic  inflaiiiniation  of  the  liiiinu-  nnicous  nicndiranc  of  tlic  uterus, 
and  is  known  l)y  llic  name  of  clirctnic  uterine  Ieneoi*rlia;a  or  eatarrli. 
Confined  to  tlie  cervical  canal,  it  lias  been  called  hy  the  hyijrid  tei  in, 
"chronic  cndoccrvicitis,"  also  "cervicitis,"  but  inap})ropriately.  The 
term  "  cudotraeholitis  "  is  proper,  and  that  of  "chronic  cervical  endo- 
metritis "  defines  very  correctly  both  the  nature  and  the  scat  of  the 
atlection  when  the  cervical  canal  alone  is  involved.  Limited  to  the 
corporeal  cavity  of  the  uterus,  the  disease  has  been  entitled  "  chronic 
internal  metritis,"  also  "  fundal  endometritis."  But  for  reasons  just 
stated  this  form  of  the  disease  is  best  known  by  the  appellation  of 
"chronic  corporeal  endometritis." 

Divisions. — Three  varieties  of  chronic  endometritis  are  recf)":nized, 
a  division  which  clinical  experience  and  post-mortem  examination  sanc- 
tion.    Thus  : 

1.  Chronic  cervical  endometritis; 

2.  Chronic  general  endometritis  ; 

3.  Chronic  corporeal  endometritis. 

This  is  the  order  of  frequency  of  the  different  varieties. 

It  has  been  observed  for  a  long  time — a  pbint  persistently  held  by 
Bennet — that  chronic  inflammation  very  often  confines  itself  to  one  por- 
tion of  the  uterus,  especially  the  cervix,  without  invading  the  other. 
Various  reasons  have  been  assigned  for  this  peculiarity  of  self-limita- 
tion of  the  chronic  type  of  the  disease,  which  does  not  hold  true  in  the 
acute.  For  the  most  part,  these  reasons  jiertain  to  the  diiferences,  both 
anatomical  and  phvsiological,  between  the  cervix  and  corpus  uteri. 
The  decided  distinction  in  the  pathological  proclivities  of  the  two 
parts  is  also  evidenced  by  the  frequent  sharp  limitation  of  tubercular 
disease  to  the  body,  and  cancerous  disease  to  the  neck,  of  the  uterus. 

The  three  forms  of  chronic  endometritis  will  noAv  be  consideretl  in 
their  order. 

CHRONIC    CERVICAL   ENDOMETRITIS. 

Frequency.- — It  is  more  than  probable  that  chronic  inflammation 
of  the  mucous  membrane  of  the  cervical  canal  and  the  exterior  of  the 
infravaginal  cervix  is  the  most  frequent  disease  of  the  female  pelvic 
organs.  A  vast  majority  of  all  women  seeking  advice  for  chronic  pel- 
vic disease  have  this  aifection,  either  independently  or  complicating 
some  other.  Considering  the  position  of  the  cervix,  its  exposure  to 
injury  in  coitus  and  parturition,  this  statement  excites  no  surprise. 
Chronic  catarrh  of  the  cervical  canal  is  infinitely  more  frequent  than 
of  the  upper  uterine  cavit}\ 


550       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

Pathological  Anatomy. — Chronic  cervical  endometritis  is  essen- 
tially a  glandular  disease.  The  first  step  in  the  pathology  is  a  hyper- 
emia of  the  peculiar  follicles  of  the  cervical  canal,  the  glands  of  Naboth. 
These  become  swollen,  enlarged,  elevated,  with  dilated  mouths,  and  in 
consequence  there  is  a  hypersecretion  from  them.  Increased  is  soon  fol- 
lowed by  an  altered  secretion.  At  first  it  is  thin,  glairy,  alkaline,  like 
the  white  of  an  egg ;  then  it  becomes  thicker,  more  tenacious,  and 
adhesive ;  later,  decidedly  albuminous,  loaded  with  epithelial  cells ; 
and  finally  it  may  be  yellow  and  tinged  with  blood.  Within  the 
vagina,  owing  to  an  acid  secretion,  the  discharge  sometimes  assumes 
the  appearance  of  coagulated  white  of  egg.  Another  feature  of  its 
altered  character  is  its  acridity,  exercising  a  manifest  erosive  influence 
on  the  surrounding  cervical  mucous  membrane,  already  softened  and 
hypersemic.  Thus,  an  increased  and  altered  secretion  jjroduces  disin- 
tegration of  the  epithelial  layers,  and  creates  what  is  known  as  abrasion 
or  erosion  (Plate  II.  figs.  1,  2),  the  most  superficial  form  of  ulceration. 
For  the  most  part  this  erosive  process  is  noticeable  in  the  region  of  the 
OS  externum,  but  may  extend  up  the  cervical  canal. 

The  disease  progressing,  it  begins  to  effect  changes  in  the  mucous 
membrane  proper,  already  denuded  of  epithelium.  In  the  papillae 
a  proliferative  inflammation  occurs.  These  papillae  undergo  hyper- 
trophy, constituting  a  process  known  as  granular  degeneration  or 
the  granular  ulcer  (Plate  II.  fig.  3).  The  labia  uteri  are  now  tumid, 
pointing,  the  os  externum  patulous ;  the  whole  cervical  canal  is  larger, 
and  loses  in  a  measure  its  natural  fusiform  shape.  In  some  instances 
the  constant  catarrh  with  an  attendant  tenesmus  leads  to  eversion  of 
the  cervical  mucous  membrane.  Should  the  inflammatory  action  pro- 
gress still  farther,  a  well-defined  or  true  inflammatory  ulcer  would  be 
formed.  While  such  a  result  is  possible,  it  is  among  the  rarest  of  occur- 
rences. 

Localization  of  the  disease  in  the  muciparous  follicles  of  the  infra- 
vaginal  cervix  creates  enlargement  in  them,  distension,  bursting,  a 
follicular  ulceration  (Plate  II.  fig.  4) — a  process  which  in  its  entirety 
is  called  cystic  degeneration.  Hypertrophy  of  the  Nabothian  glands 
may  be  carried  to  such  an  extent  that,  either  singly  or  in  aggregation, 
they  partake  of  the  shape  of  polypi.  In  old  cases  hyperplasia  of  the 
mucous  membrane  and  adjacent  fibrous  tissue  may  be  noticeable. 

The  steps,  then,  in  the  pathogenesis  of  the  disease  are — 

1.  Increased  and  altered  secretion,  incident  to  the  changes  in  the 
Nabothian  glands. 

2.  Erosion  of  the  epithelium. 

3.  Granular  degeneration  of  the  villi  of  the  mucous  membrane. 

4.  Dilatation  of  the  os  externum  and  lower  cervical  canal. 

5.  Eversion  of  the  cervical  mucous  membrane. 


Fife  3 


Fi^.4- 


Fig.l  .   Ei-owicjiL  of    tlie    Cei>\-ix    (Meiji;s). 

FMg.2.  Follicvilar  Erosion  ^vith   slight  Jjacei-Mtioix  (Muride). 
Fig  .  :i  .  Gr-aTTiala-n  De  gerLt»r>Mlion  of  an  Eloia^aled  Cervix    (Mei^s) 
Fig. 4  .  Krosiot-i.C'ystic!  Enlargement  ,C'al  arrli  of  Cervix  (Meigs). 

To  face  page  .550. 


ciiRoMf  rjJin'JcAL  KM)()Mj:rniTis.  r,r,] 

().    K<»lliciil:ir  ulceration  and  dcj^ciu'ratioti. 

It  imist  not  Ih'  inllrrt'd  that  all  or  most  ol' tlicso  changes  are  (•.\liil)itod 
in  every  ease,  for  thev  are  not.  Indeed,  in  a  certain  lew  all  that  can 
l)c  noticiHl  on  the  most  <-aret'ul  inspection  throu;^h  the  speculum  is  the 
chaiaiteristie  «lis(har«ie  issuing  from  the  os  externmn,  the  infravajrinal 
cervix  appearin«j;  perfectly  normal' 

Etiolocy. — It  is  not  only  pn»per,  hut  necessary,  in  a  lull  considera- 
tion of  the  etiolo<;y  of  this  disease,  to  study  the  causes  under  two  heads, 
prtHJisposino;  and  exciting.  The  former  are  usually  general  or  constitu- 
tional, and  the  latter  local. 

A.  Pi'cdlxpm'niff  Ont.se.s. — Under  this  heading  are  include<l — 1.  The 
various  diatheses  and  blood-disorders,  as  scrofula,  tuberculosis,  syphilis, 
rheumatism,  gout,  rheumatic  gout,  antemia,  chlorosis,  leukaemia,  chronic 
albuminuria,  malarial  poisoning,  etc.  In  most  of  these  affections  the 
mucous  membranes  of  the  body  in  general  show  a  special  tendency 
to  local  manifestations  of  the  general  state,  that  of  the  uterus  being  by 
no  means  the  only  surface  affected,  chronic  pharyngitis,  br<jnchial  or 
gastric  catarrh,  granular  eyelids)  for  instance,  being  present.  Chronic 
nterine  catarrh  is  exceedingly  common  in  phthisical  and  stnimous 
subjects. 

2.  A  Natural  or  Acquired  Feebleness  of  Constitution. — Good  general 
health  is,  as  a  rule,  essential  for  a  healthy  sexual  system.  A  poor 
inheritance,  an  arrested  or  imperfect  physical  development,  tend  to 
make  one  liable  to  local  affections.  It  is  a  matter  of  common  obser- 
vation that  certain  temperaments,  notably  the  lymphatic,  and  females 
of  the  blonde  complexion,  are  the  most  frequent  subjects  of  leucorrhoea. 

All  those  diseases  and  modes  of  life  which  depreciate  and  undermine 
the  general  health  predispose  to  mucous  inflammation  of  the  uterus.  A 
cervical  catarrh  may  first  manifest  itself  during  the  convalescence  of 
some  acute  affection.  This  local  disease  too  frequently  insidiously 
develops  in  women  from  bad  hygiene,  close  confinement  indoors, 
indolent  habits,  insufficient  and  improper  food,  fiilse  habits  of  dress, 
fashionable  dissipation,  etc.,  through  the  impress  these  means  make  in 
enfeebling  the  general  health.  Nutrition  becomes  faulty,  the  balance 
between  waste  and  repair  is  lost,  the  blood  is  impoverished,  and  func- 
tion is  disturbed. 

In  a  like  manner,  on  the  nervous  system  the  depressing  effects  of 
grief,  as  well  as  the  pernicious  influence  of  our  modern  system  of 
schooling  girls  in  their  most  important  years  of  growth,  may  operate. 
It  is  a  lamentable  fact  that  the  health  of  thousands  of  our  American 

'  The  forejroinjj  represents  the  status  of  tlie  patliological  conditions  as  generally 
accepted  until  some  most  recent  investigations  made  hy  Riige  and  Veil  have  taken 
exceptions  concerning  part  of  them.  The  author  has  preferred  to  embody  these  views 
in  full  under  the  heading  of  ''  Degenerations  of  the  Cervix." 


552       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

girls  is  broken  during  the  last  years  of  an  arduous  school-life,  never  to 
be  fully  regained,  and  the  seeds  of  some  pelvic  disease  sown,  never  to 
be  entirely  eradicated. 

Prolonged  and  excessive  lactation,  frequent  childbearing,  favor  the 
development  of  chronic  uterine  disease,  doubtless  owing  to  the  exhaust- 
ing effects  of  the  drain  on  the  general  health  ^vhich  an  undue  perform- 
ance of  these  functions  involves. 

Many  of  the  well-known  exciting  causes  may  utterly  fail  to  bring 
about  local  disease  without  some  constitutional  morbific  force  operative 
in  the  background.  In  this  way  a  discovery  of  one's  actual  standard 
of  general  health  is  revealed.  As  Paget  expresses  it,  "  The  intensity 
or  quantity  of  a  constitutional  disease  or  disposition  to  disease  may  be 
estimated  as  in  inverse  proportion  to  the  amount  of  disturbance  requisite 
to  bring  about  a  local  manifestation." 

Very  many  diseases  and  injuries  severely  test  and  accurately  estimate 
the  degree  of  imperfection,  so  to  speak,  of  constitutions.  Local  path- 
ological changes  in  a  constitution  where  the  standard  of  health  is  at  par 
should  be  in  proportion  to  the  local  exciting  causes.  Recoveries  from 
such  should  be  regular  in  time  and  method.  Deviations  therefrom 
exist  only  from  some  constitutional  wrong. 

B.  Exciting  Causes. — Chronic  inflammation  of  the  cervical  mucous 
membrane  frequently  follows  the  acute,  puerperal  or  non-puerperal, 
from  which  recovery  is  not  complete,  either  on  account  of  neglect, 
bad  management,  or  some  vice  of  the  general  system.  It  may  be  an 
extension  downwardly  of  an  inflammation  within  the  upper  uterine 
cavity,  or  upwardly,  from  the  vagina,  especially  in  the  specific  forms 
of  the  disease. 

The  newly-married,  and  more  particularly  prostitutes,  often  suifer 
from  this  disease  as  a  result  of  an  abuse  of  the  sexual  function.  The 
use  of  cold-water  vaginal  injections  and  various  other  methods  to  pre- 
vent impregnation  and  produce  abortion  are  fruitful  sources  of  the 
disease. 

Injuries  to  the  cervix  in  parturition,  and  in  the  non-gravid  state 
from  the  use  of  sounds,  tents,  and  pessaries,  are  prominent  pathological 
factors.  Among  them  none  are  more  potent  than  lacerations  of  the 
cervix  in  parturition,  especially  if  well  defined,  bilateral,  multiple,  or 
stellate.  Very  often,  indeed,  lacerations  of  the  cervix  are  not  recog- 
nized at  the  time  of  the  accident,  consequently  no  attention  is  directed 
thereto  to  secure  union.  Healing  is  imperfect,  and  the  cervix  is  left  in 
a  condition  of  persistent  irritation  and  inflammation. 

Syimptoj^iatology. — Chronic  cervical  endometritis  is  often  so  slow 
and  insidious  in  its  inception  and  progress  that  the  disease  may  con- 
tinue for  some  time  without  the  presence  of  any  special  symptoms 
denoting  its  existence. 


ciinosic  cEiivicM.  i:M>()Mi:rii!Tis.  r,.-,.-. 

The  local  symptoms  will  usually  lu'  tiist  iiiaiiifot,  Amoiiw-  tlicst- 
prominently  stands  Ictu'orrlui'a.  Its  r{'<'oi;nition  by  the  patient  dcjM'nds 
hir<i-elv  upon  her  hahits  of  juTsonal  cleanliness.  l*atient.s  will  some- 
times say  there  is  no  lencori-lnea  when  a  specnhim  examinati«Mi  reveals 
its  presence  in  «:;reat  ahiuidancc.  The  dischari^c  is  thick,  vis(;id,  tena- 
cious, hit;hly  albuminous,  and,  in  severe  eases,  nnjco-purulent  or  tin«i'ed 
with  blood.  As  it  pours  forth  from  the  va<::ina  it  sometimes  assumes  a 
coaiiulated  appearance.  It  is  always  present,  and  ii.-ually  the  (piantity 
is  in  proportion  to  the  activity  and  extent  of  the  local  disease. 

The  next  symptom  is  pain  in  the  pelvic  reij:i()n,  the  hind,  de}j;ree,  and 
exact  seat  being  subject  to  much  variation.  Ordinarily,  the  first  mani- 
festation of  pain  is  backache  in  the  sacral  and  hnnbar  regions,  and  then 
dragging  sensations  in  the  hypogastrium,  inerea.sed  by  standing,  walk- 
ing, and  during  menstruation.  Coitus  becomes  more  or  less  painful, 
urination  more  frequent  than  normal,  and  somewhat  painful ;  defeca- 
tion, though  less  often,  may  also  be  attended  with  discomfort.  Men- 
struation may  be  deranged  its  to  its  frequency,  duration,  quantity,  (pial- 
ity,  or  the  presence  of  pain,  directly  resultant  on  the  local  lesion,  or 
indirectly  incident  to  the  constitutional  condition,  especially  the  changed 
state  of  the  blood. 

It  is  merely  a  question  of  time  for  the  local  disease  to  make  its 
impression  on  the  general  health.  General  symptoms  arise  with  a 
degree  of  rapidity  proportioned  to  the  vigor  of  the  constitution,  its 
power  of  resistance,  and  as  to  Avhether  the  local  disease  has  a  general 
or  local  origin.  Sooner  or  later,  the  patient  begins  to  look  pale,  loses 
weight,  is  more  easily  fatigued,  and  lacks  her  accustomed  energy.  The 
appetite  is  poor,  digestion  is  slow,  feeble,  and  disturbed,  expressed  by  a 
sense  of  heaviness  after  meals,  acidity,  flatulency,  nausea,  or  vomiting. 
The  bowels  are  usually  constipated,  the  stools  often  being  hard,  drv, 
and  insufficient. 

Resultant  (^n  a  depreciation  of  the  general  health  from  impaired 
nutrition  and  from  a  direct  sympathy  of  the  various  portions  of  the 
body  with  the  local  disease,  there  are  displayed  various  disturbances  of 
circulation,  respiration,  and  secretion,  and  also  in  the  nervous  svstem 
of  motility  and  sensation.  The  latter  rank  most  conspicuous  among 
these.  The  patient  becomes  nervous,  irritable,  excitable,  and  hyster- 
ical. 

It  is  in  connection  with  the  other  inflammations  of  the  uterus,  es]ie- 
cially  of  its  body,  that  these  reflex  disorders  will  be  more  fully  dis- 
cussed, for  it  is  with  them  that  they  are  more  commonly  associated. 
Local  and  general  symptoms  do  not  always  hold  a  direct  relationship 
to  the  quantity  of  the  local  disease.  In  many  cases  they  are  out  of  all 
proportion  to  it. 

Physical  Signs. — 1.  By  Touch. — In  well-definetl  cases  a  digital 


554       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

examination  reveals  the  os  externum  and  lower  cervical  canal  more  or 
less  patulous,  somewhat  roughened  or  irregular  in  shape,  especially  in 
multiparse  and  if  there  has  been  laceration  of  the  cervical  walls.  The 
cervix  may  be  slightly  enlarged  from  infiltration,  hyperplasia,  and 
granular  degeneration.  The  ISTabothian  glands  as  enlarged  bodies 
may  be  felt. 

Any  great  tenderness  in  uncomplicated  cases  is  not  marked,  nor  is 
the  position  of  the  uterus  altered. 

In  the  comparatively  uncommon  instances  where  the  interior  canal 
is  solely  affected  no  dilatation  of  the  os  may  be  present,  and  touch  may 
elicit  no  evidence  of  the  inflammation, 

2.  By  Speculum. — The  cervix  well  exjDOsed  by  the  sj)eculum,  the 
regions  of  the  os  externum  and  cervical  canal  are  generally  found  filled 
with  the  characteristic  albuminous  discharge,  so  tenacious  as  to  be  diifi- 
cult  to  remove.  The  cervix,  once  cleansed,  displays  the  unmistakable 
traces  of  the  epithelial  erosion,  the  granular  degeneration,  the  patulous 
OS,  the  enlarged  Nabothian  follicles,  and  the  cervical  eversion.  The 
speculum,  carefully  employed,  enables  one  to  detect  the  peculiar  dis- 
charge pouring  from  the  os,  and  clearly  establishes  the  diagnosis  in 
cases  when  touch  has  failed. 

3..  By  Sound. — It  is  unnecessary  to  make  use  of  the  sound  when  the 
symptoms  and  signs  as  revealed  by  touch  and  the  speculum  point  to  a 
limitation  of  the  catarrh  to  the  cervical  canal ;  but  if  employed  not 
nearer  than  a  few  days  to  the  menstrual  period  the  os  internum  will 
be  found  unci  dated. 

Diagnosis. — The  diagnosis  between  chronic  cervical  endometritis 
and  vaginitis  is  easy.  Its  differentiation  from  chronic  endometritis 
of  the  upper  uterine  cavity  is  much  more  difficult,  and  will  receive 
consideration  in  the  description  of  that  affection, 

CoMPLiCATioisrs. — Chronic  cervical  endometritis,  being  the  most  fre- 
quent uterine  disease,  may  be  associated  with  any  other  affection  of  the 
organ.  The  most  common  complications  are — (a)  vaginitis,  resulting 
from  the  acridity  of  the  cervical  leucorrhoea ;  (6)  cervical  metritis  ;  and 
(c)  corporeal  endometritis,  resulting  in  general  mucous  inflammation  of 
the  uterus.    Pruritus  vulvae  is  sometimes  a  very  annoying  complication. , 

Recent  investigations  and  observations  of  Championniere,  Leopold, 
Courty,  and  Mund6  leave  no  doubt  that  a  complication  which,  until  of 
late,  has  almost  escaped  detection  or  prope]-  recognition  is  occasionally 
present — ^viz,  lymphadenitis  and  lymphangitis,  diseases  resulting  from 
direct  extension  of  the  inflammation  to  the  parametritic  lymphatic  ves- 
sels by  absorption  of  infecting  secretions  from  the  cervix. 

Duration. — The  continuance  may  be  indefinite,  for  it  has  no  self- 
limitation.  Once  well  established  and  left  to  itself  without  medical 
aid,  it  tends  to  progress  and  gradually  bring  into  train  various  compli- 


c'JiiioMc  ch'JiyicAL  i:si)()Mi:ri:iris.  TjOg 

■cations.      D()iil)tk'ss,  niild  cases  in  <i;()0(l  (•(iMstiliitii)iis  ni:iv  nndci'LTd  .-|»(»n- 
tanoons  cure.      'Plicsc  arc  certainly  tlie  c\cc|»ti()n  and  not  tlie  rule. 

IMaxJNosis. — This  depends  upon  the  eoudilion  oi'  llie  ;:cneral  health, 
the  severity  and  tlui-ation  of  the  local  disease,  the  extent  of"  de<icnerate 
chani»es,  and  the  amount,  if  any,  of  complications.  In  estimatlni!  the 
|)roiiiio,-is  of  any  i;i\'en  case  there  is  no  more  \:dualilc  Cactoi-  than  a 
determination  of  the  state  of  tlie  <icneral  health  and  whether  the  dis- 
ease has  ha<l  a  constitutional  or  local  ori<;in.  A  seeminj;'  small  amoiuit 
of  local  disease  in  a  hrokeu-dowu  constitution  with  a  >trumous  taiut  is 
very  nnich  more  dilHcult  to  ei'adicate  than  a  lai'^-er  amoimt  of  cei-vical 
chantje  in  <i;ood  health  and  nutrition. 

Appearances  of  the  cervix  to  an  inexperienced  practitioner  are  very 
deceitful  in  a  ])rotinostic  })oint  of  view.  It  is  an  observation  borne 
out  by  the  experience  of  most  gynecologists  that  cases  with  granidar 
degeneration  of  the  infravaginal  cervix  and  patulous  os  arc  more  amen- 
able to  local  treatment  than  those  with  no  visible  changes,  but  with 
copious  tenacious  secretion  of  the  canal.  Cases  of  the  latter  descrip- 
tion are  not  only  more  difficult  of  access,  but  require,  generally,  more 
radical  measures  for  relief.  In  the  former  topical  aj)plications  addressed, 
in  j^art,  to  the  exterior  of  the  cervix  have  a  beneficial  revulsive  effect 
on  the  glandular  disease  of  the  interior. 

Treatment  is  often  tedious,  and  relapses  from  a  slight  renewal  of 
causes  liable  to  occur. 

Treatment. — This  is  divided  into  constitutional  and  local.  A  con- 
sideration of  the  former  is  omitted  at  this  place,  and  deferred  until  the 
subject  of  the  management  of  both  general  and  corporeal  endometritis 
is  reached.     To  that  section  the  reader  is  referred. 

Local  Trcaiment. —  Cases  requinng  Local  Treatment. — Reference  has 
been  made  to  the  fact  that  chronic  cervical  endometritis  does,  in  excep- 
tional cases,  undergo  spontaneous  cure.  The  cause,  generally  a  local 
one,  is  removed,  and  Nature,  aided  perhaps  by  vaginal  injections,  is 
competent  to  restore  the  integrity  of  the  parts.  Again,  by  an  improve- 
ment in  the  general  health  or  a  change  in  hygiene,  the  local  disease  is 
benefited.  Not  only  are  such  cases  exceptional,  but  they  must  be  mild 
in  character.  Most  women  who  have  suffered  for  any  considerable 
period  of  time  will  not  only  be  greatly  benefited  by  local  treatment  of 
a  judicious  nature,  but  absolutely  require  it.  A  seeming  spontaneous 
cure  is  usually  only  a  temporary  improvement.  ]\luch  controversy 
has  taken  place  as  to  whether  local  treatment  is  required — its  extent 
and  kind.  That  it  has  been  carried  too  far  by  some  \y'\X\\  limited  views 
of  the  nature  of  the  local  lesions,  and  imperfect  aj^preciation  of  their 
pathological  import,  must  be  admitted.  But  this  is  not  an  argument 
against  this  method  of  treatment ;   it  merely  indicates  an  abuse. 

Vaginal  Lijections. — The  use  of  injections  of  water,  pure  and  medi- 


556       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

cated,  within  the  vagina  and  against  the  vaginal  face  of  the  uterus,  is. 
a  matter  of  history. from  time  almost  immemorial.  There  is  no  agent 
or  means  which  has  been  used  in  a  more  uncertain  or  unscientific  man- 
ner, yet  none,  properly  employed,  capable  of  accomplishing  in  diseases 
of  the  female  pelvic  viscera  greater  good. 

Selection  of  an  Instrument. — The  old-fashioned  pewter  or  glass 
syringe  has  gone  entirely  into  disuse,  and  is  now  mentioned  only  to 
be  condemned.  The  Davidson  syringe  (Fig,  180),  well  made,  air- 
tight, and  in  good  working  order,  answers  most  purposes.  Any 
quantity  of  fluid  can  be  injected  with  it.  Its  chief  objection  consists 
in  the  fatigue  jjroduced  by  working  the  bulb  for  a  long  time — a  matter 
of  necessity  where  large  quantities  of  water  are  used.  Emmet  has 
claimed  that  there  is  a  special  advantage  obtained  from  an  interrupted 


Fig.  180. 


Fig.  181. 


Davidson  Syringe. 


Vaginal  Irrigator. 


current  in  all  cases  where  the  stimulant  and  absorbent  effects  of  hot  water 
are  desired.  The  fountain  syringe  possesses  many  most  excellent  fea- 
tures. The  bag  holding  the  water  should  have  a  capacity  of  from  two 
to  four  quarts.  Any  quantity  of  fluid  may  be  injected  without  any 
effort  on  the  part  of  the  patient ;  the  current  is  continuous  and  should 
be  small  and  without  force.  The  vaginal  irrigator  (Fig.  181)  answers 
the  same  purpose  as  the  above,  and  is  admirably  adapted  for  hospital  use. 
Whichever  of  these  instruments  is  selected,  special  care  should  be 
taken  to  close  the  central  distal  (uterine)  opening,  to  avoid  the  possi- 
bility of  the  accident  of  injection  within  the  uterine  cavity  in  cases 


cuiiosic  cEiivicAL  FSDnMiiinris.  r,r,7 

wIiciT  tlu' OS  is,  iVoin  ;iii\'  <:msc,  ]i:il iiloii-.  All  tiihcs  sliuuM  he  iiKnlc 
ot'  liai"(l  niljluT,  which  will  not  coriodc  aii<l  is  least  all('<-t<'(|  by  the 
tciiUKTatun'  ot"  the  iiot  doiicln'.  The  >i/,t'  should  !«•  siiniciciit  to  prc- 
\fiit  hreakiii}:;,  and  not  too  lar<;e  for  insertion,  'i'hc  shank  of  the  tiihc 
should  he  straiuht,  the  extremity  with  small  openin^^s,  olive-shaix'd,  and 
the  whole  lenuth  five  inches,  sniKeient  to  reach  to  the  vaj^inal  eul-de-sae 
posterior  to  the  cervix. 

3Io<h'  of  l^siiif/. — The  effects  of  vaginal  injections  are  not  fully 
obtained  in  the  ordinary  erect  or  sitting  ])osture,  where  the  abdcjminal 
and  pelvic  viscera  are  crowded  down,  the  vagina  shortene<l,  and  the 
cervix  made  to  a])j)roach  the  vnlvar  orifice.  The  fluid  more  readily 
escapes,  failing  to  reach,  as  it  should,  every  portion  of  the  vagina; 
tlierebv  the  special  effect  of  the  injection,  whether  detergent,  absorbent, 
anodyne,  or  astringent,  is  lost.  Moreover,  the  uterus,  from  a  c-hange  in 
its  axis  and  its  separated  cervical  lips,  is  more  apt  to  be  distended  with 
fluid.  The  dorsal  recumbent  position  is  worthy  of  the  highest  recom- 
mendation. With  hi])s  elevated  and  shoulders  depressed,  the  abdominal 
viscera  gravitate  toward  the  diaphragm,  the  vagina  lengthens,  and  its 
whole  cavity  is  flooded  with  fluid,  a  certain  portion  of  which  remains 
around  the  cervix  until  the  erect  posture  is  assumed.  This  position, 
with  the  quantity  tjf  water  required,  demands  the  use  of  some  special 
means  as  a  receptacle  for  the  fluid  as  it  flows  from  the  vulvar  oi-ifice. 
A  round,  flat  be<l-pan,  of  large  capacity — or,  better  still,  one  Avith  an 
outlet  pipe  and  rubber  tube  attachment — or  a  rubber  sheet  suital)ly 
folded  over  the  side  of  the  bed,  hanging  in  a  tub  below,  upon  which 
and  over  the  edge  of  the  bed  the  hips  of  the  patient  rest,  with  feet  on 
two  chairs,  fulfils  the  necessary  indications.  Sometimes  a  contrivance 
which  tightly  fits  to  the  vulva  and  prevents  the  escape  of  the  fluid, 
€xce})t  through  an  efferent  tulje,  is  very  useful.  By  it  the  exterior 
organs  are  protected  from  the  irritating  effects  of  the  hot  douche,  and 
the  patient  is  kept  dry,  and  a  more  thorough  retention  and  distension 
of  the  vaginal  canal  are  secured.  Dr.  Frank  P.  Foster  has  introduced 
such  an  instrument. 

In  addition  to  the  dorsal  decubitus,  which  is  ordinarily  resorted  to 
in  the  manner  dest-ribecl,  ]>atients  may  be  ])laced  in  the  knee-chest  pos- 
ture when  it  is  thcjught  best  to  further  distend  the  vagina  and  ensure 
longer  retention  of  medicated — especially  disinfecting  and  astringent 
— hot- water  injections.  The  position  itself,  through  the  influence  of 
gravitation,  pov.erfully  aids  in  diminishing  pelvic  congestion.  The 
proper  administration  of  injections  in  ttese  positions  is  best  obtained 
by  the  attendance  of  an  assistant. 

Temperature. — Vaginal  injections  are  used  cold,  cool,  tepid,  warm,  or 
hot.  If  it  is  desirable  to  cleanse  the  infravaginal  cervix  and  vaginal 
tube  of  all  discharges,  a  warm  injection,  ranging  from  85°  to  100°  F., 


558       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

is  indicated.  If,  on  the  other  hand,  in  addition  to  the  above  it  is  neces- 
sary to  control  pelvic  circulation  for  the  relief  of  venous  congestion,  the 
temperature  must  be  hot,  commencing  at  about  100°  F.  and  daily, 
gradually,  increasing  it  until  it  has  reached  120°  F.  or  more.  The 
primary  effect  of  water  at  this  high  temperature  is  to  produce  a 
dilatation  of  the  blood-vessels,  but  of  short  duration.  The  secondary 
effect,  which  more  quickly  follows  and  is  more  permanent,  provided  the 
quantity  is  sufficient,  is  contraction.  For  a  full  understanding  of  the 
beneficial  effects  of  hot- water  injections  the  profession  is  indebted  to 
Emmet. 

Quantity. — A  cleansing  injection  does  not,  generally,  require  more 
than  a  quart  of  fluid.  For  astringent  purposes  less  is  needed ;  for  dis- 
infection more  will  be  advantageous.  But  when  it  is  designed  to  obtain 
the  thermic  qualities,  the  quantity  ought  to  be  very  large,  ranging  from 
half  a  gallon  to  several  gallons  at  each  sitting.  The  current  should  be 
projected  steadily  or  with  interruptions  for  twenty  to  thirty  minutes. 

Frequency. — Under  almost  any  circumstances  when  injections  are 
demanded  to  remove  or  control  diseases  of  the  cervix  and  vagina  at 
least  two  are  needed  daily,  and  they  may  with  decided  advantage,  in 
some  cases,  be  administered  oftener. 

Indications. — (a)  To  cleanse  with  warm  water  the  infravaginal  cer- 
vix and  vaginal  canal  of  morbid  secretions,  thereby  favoring  the  heal- 
ing processes  in  the  former  and  preventing  secondary  inflammatory 
action  with  its  results  in  the  latter ;  (6)  to  medicate  these  surfaces  with 
emollients,  anodynes,  astringents,  or  antiseptics,  according  to  special 
local  lesions;  (c)  to  contract  with  hot  water  the  blood-vessels  and 
diminish  congestion  of  the  cervix  and  its  surroundings  in  the  manner 
detailed.  A  permanent  restoration  of  the  tone  and  calibre  of  the  blood- 
vessels is  of  paramount  importance  in  the  successful  management  of 
these  cases ;  and  this  is  a  means  to  that  end  not  to  be  neglected.  As 
one  of  the  immediate  effects  of  such  injections  is  to  diminish  local  pain 
and  soothe  the  irritable  organs,  thereby  conducing  to  sleep,  the  best 
time  for  such  administration  is  on  retiring.  At  this  time  also  oppor- 
tunity is  obtained  through  bodily  posture  to  maintain  a  more  perma- 
nent effect  of  capillary  contraction. 

The  various  astringents — plumbic  acetate,  zinc  sulphate  and  chlo- 
ride, tannin,  alum — simply  or  in  combination,  are  often  efficacious 
where  the  vaginal  face  of  the  cervix  is  eroded,  granular,  and  there  are 
secondary  vaginitis  and  pruritus.  But  milder  agents,  as  pure  castile 
soap,  glycerin,  sodium  chloride,  sodium  biborate,  boric  acid,  are  ordi- 
narily not  only  more  conducive  to  comfort  than  astringents,  but  answer 
all  the  purposes  of  medicaments. 

Contraindications. — Vaginal  injections  should  not  create  any  pain  or 
uneasiness.     Reference  has  been  made  to  the  possible  accident  of  the- 


ciH!().\/(  •  ( 'i:n  i k  -. i  l  hwno.y/rnnT/s. 


•Oof) 


Fig.  182. 


injected  lliiid  i('achin<i;  tlic  niiiinc  cavil y  because  of  son n-  liniliv  <i(ii- 
struotion  or  actit)ii  of  thv  iiistriiiiiciit,  carck'ssncss  in  its  use,  or  <>rcat 
patiiltnisne.ss  of  the  cervical  canal.  This  accident  i-cally  fi('<jncntlv  lia|>- 
peiis.  Numerous  instances  of  serious  results,  even  deaths,  have  (icnir- 
rcd  and  hccn  rcportetl.  With  proper  care  such  need  rarciv  take  jdacc. 
Occasionally  there  follows  such  a  degree  of  pelvic  discomfort  after 
injections,  althoutih  neither  fluid  nor  air  has  entered  the  uterine  eavitv, 
that  the  jiractitioner  may  he  obli<i;ed  to  recommend  their  discontinnaiice 
or  modification.  l*rol)ai)ly  these  symptoms  are  explieahle  on  the  <^i'ound 
of  special  tenderness  of  the  uterus  or  periuterine  tissues,  or  that  the 
injections  are  administered  at  first  at  too  high  a  tem|)erature.  Gen- 
erally, all  that  is  required  to  meet  such  indications  is  to  lower  the  tem- 
perature of  the  water,  and  then  slowly  increase  it. 

Topical  Applicdtion.s. — The  propriety  of  direct  topieal  api)lications 
of  medicinal  agents  to  the  diseased  cervix  is  the  same  as  for  any  portion 
of  the  body,  and  to  a  great  extent  the  same  prin- 
ciples guide  us.  The  medicaments  are  cukjI- 
lients,  anodynes,  astringents,  alteratives,  and 
caustics. 

The  following  principles  of  local  treatment 
should  always  be  held  in  view:  1.  Thorouoh 
cleanliness  of  the  diseased  surfaces ;  2.  Proper 
selection  and  adaptation  of  the  medicinal  ap- 
plication to  the  individual  case  or  condition  ; 
3.  Thoroughness  of  application ;  4.  Proper  in- 
tervals between  applications ;  5.  Careful  atten- 
tion to  the  approach  of  an  oncoming  menstrual 
epoch  and  to  that  which  has  just  closed. 

The  first  is  to  be  secured  by  a  copious  warm 
or  hot  vaginal  injection  preceding  the  introduc- 
tion of  the  speculum.  The  cervix  uteri,  now 
being  engaged  Ijv  a  speculum,  is  cleansed  with 
small  pieces  of  dry  absorbent  cotton,  or  by  soft, 
clean,  fresh  sponge  squeezed  out  of  hot  water, 
pure  or  medicated  with  sodium  chloride,  firmly 
seized  with  the  dressing-forceps.  The  cervical 
canal  requires  particular  attention.  If  it  is  much 
dilated  the  above  means  answer,  but  if  narrow 
it  is  better  managed  with  the  cotton-wrapped 
probe.  Thomas  recommends  a  syringe  for  the 
purpose  of  removing  the  tenacious  secretion 
which  plugs  the  cervical  canal.  Whatever 
method  is  used,  thoroughness  is  of  the  utmost  importance,  not  only  on 
the  exterior  of  the  cervix,  but  in  the  interior  canal,  fi)r  the  medicament 


Peaslee's  Dilators  fprraduated). 


560       THE  INFLAMMATORY  AFFECTIONS   OF  THE    UTERUS. 


is  generally  to  be  carried  to  within  the  latter.  It  is  ever  to  be  held  in 
mind  that  the  disease  on  the  vaginal  face  of  the  cervix  is  rarely  the 
whole  affected  surface.  Usually,  it  is  only  pathognomonic  of  the  glan- 
dular inflammation  within,  which,  if  untouched  and  uncontrolled,  will 
surely  cause  a  relapse  of  the  erosion  and  granular  degeneration,  it 
matters  not  how  effectually  they  may  have  been  removed. 

The  disease  itself  so  often  opens  up  the  cervical  canal  that  dilatation 
by  artificial  means  is  comparatively  rarely  required.  A  successful  issue, 
hovv^ever,  in  cases  of  chronic  catarrh  of  the  cervical  canal,  where  the 
vaginal  face  remains  healthy  and  the  os  externum  is  not  rendered  patu- 
lous, makes  dilatation  necessary.  We  have  for  this  purpose  the  metallic 
dilators  fashioned  after  the  patterns  of  Peaslee  (Fig.  182),  or  Ellinger, 
or  some  of  their  modifications.  Preference  is  given  to  those  with  expand- 
ing blades.     The  author's  (Fig.  183),  which  he  has  used  since  1874,  is 

Fig.  183. 


Palmer's  Uterine  Dilator. 

simple  in  mechanism,  easy  of  introduction,  and  if  properly  constructed 
secures  an  absolute  parallelism  of  dilatation,  from  out  to  out,  of  three- 
fourths  of  an  inch.  A  larger  size  also  is  now  made  when  greater  dila- 
tation is  desirable  under  other  circumstances. 

Ji  free  dilatation  is  sought  in  order  to  provide  for  a  thorough  applica- 
tion of  some  caustic  agent,  the  choice  is  given  to  tents  of  sponge,  tangle- 
weed,  or  tupelo.  The  superior  advantages  of  the  tupelo  tent,  introduced 
to  the  profession  by  Dr.  G.  E.  Sussedorff,  over  the  other  materials  are 
now  generally  recognized  bv  gynecologists.  It  possesses  the  better 
qualities  of  both  sponge  and  the  tangle,  without  some  of  the  disad- 
vantages of  either.  By  it  the  cervix  can  be 
effectually  expanded,  at  the  same  time  softened, 
and,  being  free  from  fetor  and  not  tearing,  the 
mucous  membrane,  the  clangers  of  septic^emic 
inflammation  are  reduced  to  a  minimum. 

Incisions  of  the  mucous  membrane  with  a 
knife  before  or  in  view  of  dilatation  with  tents, 
as  recommended  by  some,  are  unnecessary  and 
of  doubtful  propriety. 

But  there  is  a  class  of  cases  of  chronic  cer- 
vical catarrh,  for  the  greater  part  confined  to  nulliparous  single  women 
or  sterile  married  women,  where  thorough  and  permanent  dilatation  by 


Fig.  184. 


Conoid    Cervix,   Pinhole    Os, 
the  canal  seat  of  catarrh. 


(  IinoXK '  CKR VICAL  KMioMiynuris. 


'>i;i 


Fig.  185. 


iiicisi(iii>  ur  the  t'oi-ccps  dilatnrs  is  ui'  inijx'ral  ixc  ii<'<'i'>sity.  'I'Ik- calarrli 
is  due  to  a  iiaiTnw,  ••oii.-.trictrd  os,  jti'<'\ciitiiiL:  a  IVcc  exit  ot"  iiurmal  sc.-crc- 
tiniis  ot"  iiiiicus  ami  iiiciistnial  tltiid.  The  al)iii)riiiity  is  jiciH-rallv  <-(iii- 
gc'iiital,  and  nMd(iul)t('dly  iii(»st  ••((iiiiiioii  at  the  <js  cxtcniimi.  TIk; 
cervix  is  loiiii',  narrow,  conoid  ;  its  canal,  in  con>c(|nciicc  of  pciit-uj) 
fluids,  dilated  ( I'^i;^'.  1 -S 1).  Ac<jnircd  cases  of  stenosis  are  Ic.-s  fre- 
i^nent,  and  are  r'esnltant  on  the  vicious  nse  of  caustics.  .V  thick  plnji;  of 
mucii.s  han>>inj;  from  the  os,  and  its  free  flow  after  the  withdrawal  of 
a  sound,  are  proof  of  an  accnnudation  and  retention.  Tlie  retention  of 
even  normal  secretion  leads  to  acridity  and  its 
results.  Topical  applications  of  medicine,  the 
curette,  etc.  caiuiot  possibly  he  of  any  lastinu- 
service.  Dilatation  by  tents  is  insutticient, 
for  its  effects  are  only  temporary.  Bilateral 
or  (juadri lateral  incisions  (Fi<r.  185)  as  rec- 
ommended by  Fritsch  and  Munde,  made 
deep  enough  to  open  uji  the  os  as  wide  as 
the  canal  above,  with  precautions  to  main- 
tain the  same,  are  attended  with  the  greatest 
benefit,  and  may  be  all-sufficient.  Thorough 
divulsion  of  the  cervical  walls  by  a  strong 
expanding  dilator  has  also  led  to  very  good 
results. 

The   frequency    of    applications    depends 
largely  upon  the  choice  of  the  agent.     The 

mistake  is  often  made,  and  patients  are  in  Dilated  canai,  from  obstruction 
numerous  instances  given  unnecessary^  pain, 
wiiile  at  the  same  time  the  healing  processes 
are  delayed,  by  too  frequent  and  uncalled-for  applications.  No  agent 
should  be  applied  or  reapplied  until  the  effect  of  a  former  one  has 
passed  away. 

Another  factor  which  should  govern  the  frequency  of  topical  appli- 
cations is  the  special  physical  or  mental  susee]iti):)ility.  Comparatively 
mild  agents,  sometimes  without  any  discernible  contraindication,  unex- 
pectedly set  up  irritation  and  pain.  Hence  the  interval  must  be  length- 
ened. Again,  there  are  those  Avho  are  profoundly  disturbed  in  their 
nervous  system  by  any  local  treatment.  The  jjractitioner  may  be 
forced  to  abandon,  or  at  least  to  suspend  for  a  while,  such  man- 
agement. 

It  is  always  desirable  that  local  examinations  and  treatment,  even  in 
married  women,  be  reduced  to  a  minimum  consistent  with  recovery. 
In  virgins  only  where  constitutional  measures,  judiciously  tried,  have 
failed,  and  there  is  some  special  urgency  required,  are  they  justifi- 
able. 

Vol.  I.— 36 


at  Os  Externum :  lines  for  in- 
cision (Munde). 


562       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

It  is  almost  unnecessary  to  remind  the  reader  that  the  greatest  cau- 
tion is  to  be  indulged  in  whenever  a  digital  examination  bespeaks  any 
evidence  of  an  old  chronic  perimetritic  inflammation. 

The  physician  should  be  watchful  as  to  the  time  of  the  closing  of  the 
last  and  the  approach  of  the  oncoming  menstrual  epoch.  The  more 
potent  the  local  agent  in  its  effects,  the  farther  removed  it  should  be 
from  the  dates  of  menstruation.  As  a  rule,  local  treatment,  even  of  a 
mild  character,  ought  to  be  suspended  a  few  days  prior  to  the  approach- 
ing period,  and  not  resumed  again  until  as  many  days  after  its  close.  A 
disregard  of  these  minor  details  tends  to  excite  local  pain,  reflex  disor- 
ders, and  to  derange  the  time  and  quantity  of  the  menstrual  flow. 

The  choice  of  agent  is  of  paramount  importance.  The  experience  of 
the  profession,  after  many  years  of  trial,  has  now  very  fairly  defined  the 
indications  and  range  of  utility  of  local  uterine  medication.  The  time 
was,  but  fortunately  has  well  passed,  when  gynecologists  confined  them- 
selves almost  wholly  to  the  use  of  a  single  agent :  nitrate  of  silver  was 
universally  used — of  course  to  be  abused. 

So  far  as  practicable,  the  inauguration  of  local  treatment  should  be 
of  a  mild  character,  especially  if  the  disease  is  not  severe  or  its  dura- 
tion long.  Emollients,  anodynes,  astringents,  and  alterative  applica- 
tions will  cover  the  necessary  indications  for  a  large  proportion  of 
cases. 

When  the  mucous  membrane  of  the  cervix  looks  highly  hypersemic 
the  use  of  mild  means  to  deplete  from  the  distended  vessels  is  always 
beneficial.  These  consist  in  the  local  abstraction  of  blood  by  super- 
ficial scarification  of  the  region  of  the  os  and  cervical  canal  or  by  punc- 
turing the  vaginal  face  of  the  cervix.  Either  may  be  followed  by  the 
application  of  a  tampon  of  absorbent  cotton  saturated  with  pure  anhy- 
drous glycerin.  If  pain  is  a  prominent  feature  of  the  local  symptoms, 
the  glycerin  may  be  medicated  with  morphina  sulphate  (gr.  |-|-)  or  aque- 
ous extract  of  opium  (gr.  j-ij)  to  each  drachm.  Belladonna  may  be 
chosen  with  the  same  object  in  view,  and  is  thought  by  some  (Trous- 
seau and  Ringer)  to  possess  properties  to  diminish  the  secretion  of  the 
Nabothian  follicles.  The  absorbing  power  of  the  vagina  and  cervix  is 
not  considerable — probably  not  more  than  one-fifth  of  that  of  the  stom- 
ach— but  it  is  materially  increased  by  any  superficial  loss  of  tissue,  as  in 
abrasions  and  erosions. 

The  tamponade  with  glycerin  may  be  reapplied  every  second  to 
third  day,  each  being  permitted  to  remain  some  twenty-four  hours. 
The  influence  of  pure  glycerin  thus  applied  to  the  congested  cervix, 
through  its  affinity  for  the  watery  elements  of  the  blood — a  power 
most  fully  demonstrated  in  cases  where  the  chronic  inflammation  has 
involved  the  fibrous  tissue  as  well  as  the  mucous  membrane — is 
remarkable. 


cnnoMc  cr.iivK'M.  hwnoMirrniTfs.  5g;j 

I  r  scai'irK-itiiiii  di'  |>iiiicliii'iiiLi  is  r<'|K':iti'(l,  ii  .-IkiiiM  he  at  intervals 
of  three  to  live  (la\s.  Not  all  ea.ses  ol'  clii-diiic  ceix  ical  <'ii(l()iiietritis 
re(Hiire  direct  (le|)letioii.  TIh'  ^-lyeei-iii  apiilieatiniis  in  some  form 
lia\'e  a  wider  raiii;e  ol"  iiselidness,  Ixit  the  joi'al  iniproveiiient  is  very 
lre(|iieiitly  indeed  laeiUtated  l>y  these  pi-eliniinai-y  ah.^traetioiis  oC  Mood. 
'I'he  adchtioM  of  horie  acid  to  the  t;lyeei-in — the  l)oro-^lyeeri(h'  (.")()  per 
eeiil.  >nhi(ion)— is  a  xainahle  one,  especially  il"  in  addition  t<t  th<! 
h\j)er;cniia  and  catarrh  there  is  sujx'rficial  idcei'ation.  Not  only  is 
the  tih'cerin  ot"  this  cond)iiiatioii  rendered  more  dense  and  anhydrous 
hy   heat,   hut   the  horie  acid   is  emollient   and   antiseptic. 

Anion*::  tiie  varions  astrintients  from  which  the  selection  may  be 
made,  none  is  suj)eri()r  to  tannic  acid.  Its  best  vehicle  is  glycerin 
— U'lycerite  of  tannin  (tannin  3j-ij  to  glycerin  sj).  A  tampon  of  cotton 
of  suitable  si/e  is  saturated  with  one  to  two  drachms  of  this  solution, 
and  })acked  thoroughlv  against  the  cervix  every  two  to  three  days. 
Styptic  colloid  and  concentrated  ext.  pinus  Canadensis  are  other  useful 
agents  of  the  astrintrent  class. 

Fluid  hydrastis,  though  not  an  astringent,  either  pure  or  dilute<l 
with  boro-glyceride,  is  an  excellent  application,  made  with  cotton,  for 
catarrhal  states  of  the  cervix. 

The  indications  for  astringents  are  hypersecretion,  due  to  hypeneniia 
and  relaxation  of,  the  blood-vessels  and  glands.  By  their  use  not  only 
are  the  secretions  more  or  less  checked,  but  erosions  and  granular 
degeneration  are  made  to  disappear. 

Such  applications  as  above  mentioned  are  made  only  to  the  vaginal 
face  of  the  cervix.  Here  they  produce  their  best  effect ;  indirectly  they 
iuHuence  the  morbid  conditions  of  the  canal  above.  But  one  must  not 
be  deluded  with  the  idea  that  such  treatment  will  often  suffice  to  com- 
plete a  cure.  A  permanently  good  result,  if  the  disease  is  of  k>ng 
standing  and  severe,  is  seldom  secured  unless  the  local  treatment  be 
extended  within  the  cervical  canal.  The  agents  which  may  be  intro- 
duced within  the  cervical  canal  arc> — astringents,  as  tannin,  zinc  chlo- 
ride ;  alteratives,  as  iodine  and  its  combinations ;  caustics,  as  silver 
nitrate,  carbolic  acid,  chromic  acid,  nitric  acid,  and  the  actual  cautei-y. 
There  are  many  others,  but  these  embrace  those  which  the  experience 
of  the  author  has  found  most  useful. 

For  solids,  the  method  by  suppositories,  gelatin-coated  pencils,  and 
crayons  ;  for  fluids,  that  by  the  cotton-wrapped  probe,  are  used.  Tannin 
(grs.  iij— v),  zinc  sulphate  (grs.  ij— iij),  can  be  incoi-porated  in  an  aj)pro- 
priately  sized  suppository  made  of  cocoa-l)uttcr  or  in  a  gelatin-coated 
pencil.  Either  is  inserted  into  the  cervical  canal  every  third  dav,  hehl 
in  position  by  a  packing  of  cotton  around  the  cervix,  and  allowed  to 
remain  until  well  melted. 

A  certain  amount  of  skill,  ac(|uired   only  by  ])ractice,  is  necessarv 


564       THE  INFLAMMATORY  AFFECTIONS  OF  THE    UTERUS. 


Fig.  186. 


to  prepare  the  cotton-wrapped  applicator.  The  method  is  as  follows : 
A  flexible  hard-rubber  probe  (Fig.  186),  nine  inches  long, 
with  a  bulbous  extremity  and  firm  handle,  one  face  of 
which  is  roughened,  is  to  be  preferred  to  the  silver  instru- 
ment, because  more  flexible  and  not  aifected  by  the  chem- 
ical action  of  any  agent.  A  thin  film  of  prepared  cotton 
is  wrapped  around  the  distal  extremity  for  three-fourths 
of  an  inch,  care  being  taken  that  it  is  not  too  thick  to 
pass  readily  within  the  canal  or  so  loose  that  it  may  slide 
off  The  parts  now  having  been  thoroughly  cleansed  of 
secretions  and  dried  with  absorbent  cotton,  the  cotton- 
wrapped  aj)plicator  is  dipjDed  into  the  selected  fluid  and 
pressed  against  the  walls  of  the  vial  containing  it  to  rid 
the  wrapping  of  any  superfluous  material.  Then  it  is 
gently  introduced  into  the  cervical  canal  to  the  os  inter- 
num, and  allowed  to  remain  a  few  seconds  before  with- 
drawal. Any  excess  of  fluid  which  possibly  may  be 
squeezed  from  the  applicator  and  run  down  around  the 
OS  externum  should  now  be  removed  with  sponge  or  cot- 
ton. There  are  those  who  prefer  to  make  use  of  appli- 
cations of  this  kind  without  the  speculum,  but  accuracy, 
as  well  as  neatness,  demands  the  aid  of  this  instrument. 

Iodine  in  alcoholic  solution  is  one  of  the  most  efficacious 
remedies  we  possess.  Unless  used  too  strong  or  too  often, 
it  is  not  irritant,  but  stimulant,  alterative,  and  antiseptic, 
and  is  not  altered  by  the  secretions  of  the  cervix  as  most 
medicaments  are.  The  ofl&cinal  tincture  is  usually  too 
weak.  GhurchilFs  tincture  (iodine,  grs.  Ixxv,  potassic 
iodide,  sjss,  to  alcohol  Ij),  very  much  stronger,  is  often 
to  be  preferred.  A  good  tincture  is  one  from  Bijss-3j  to 
^j,  with  a  small  quantity  of  potassic  iodide  to  facilitate 
solution.  This  can  be  applied  to  the  exterior  of  the  cervix 
and  the  canal  once  per  week  and  covers  the  indications 
for  a  large  number  of  cases.  lodo-tannin  (tannin  dis- 
solved to  saturation  in  the  foregoing  tincture  of  iodine)  answers  a 
similar  purpose,  and  may  at  times  be  beneficially  substituted. 

Carbolic  acid  (liquefied  crystals),  used  at  the  same  intervals,  is  less 
caustic  than  silver  nitrate  and  possesses  none  of  its  disadvantages. 
Locally,  it  is  auEesthetic.  Either  in  this  form  or  as  iodized  phenol 
(2  parts  of  iodine  with  8  parts  of  carbolic  acid)  it  is  a  favorite  remedy 
with  many  gynecologists. 

Nitrate  of  silver,  once  so  universally  used  for  all  cases  and  con- 
ditions, has  now  fallen  into  undeserved  disuse.  Applied  to  the  cervix, 
its  first  effect  is  to  produce  more  or  less  pain,  which  usually  passes  off* 


Hard-rubber 
Probe  Applicator. 


ClinoSlC  CI-JIVICAL    KSnoMKTIlITlS.  565 

within  a  lew  hours,  I'olldwcd  <»ii  the  si'c<»ii(I  aii<l  thii-d  chivs  hv  tnorc  or 
less  hemorrhage  from  the  caiiteri/.ed  siiri'ace,  with  extoIiati«jii  ot"  a 
superficial  eseliai*.  It  therein- aets  a.s  a  .stimulant  of- the  proa*s.ses  of 
jj^raiiiilatioii  and  cicatrization.  Sooner  or  later,  aeeordin<:;  to  the  amount 
and  I'rcnueney  of  the  cauterizations,  excessive  cicatrization  at  its  .seat 
and  condensation  of  the  sni  round iiiu-  fil)r(»us  tissue  follow.  The  cervix 
thus  becomes  harder,  den.ser,  and  the  re<^ion  of  the  o>  externum  c()n- 
tractcd — a  .stenosis,  eausinj^  sterility  and  menstrual  oljstrueti<jn.  It  is 
also  well  known  that  cicatricial  tis.sue,  by  inclusion  within  it  of  nerve- 
filauKMits,  may  jjjive  ri.^e  to  persistent  local  and  <^eneral  reflex  neu- 
ralgias. The  pain  and  hemorrlia<;e,  although  po.-^sibly  .severe,  are  not  the 
most  serious  objections  to  the  use  of  the  nitrate,  but  the  foregoing 
secondaiy  morbid  conditions  produce  effects  wonse  than  the  original 
disea.se.  There  was  a  time,  not  many  years  since,  when  acquired 
stenosis  of  the  os  and  cervical  canal  from  the  vicious  use  of  cau.stics, 
the  nitrate  of  silver  in  |)articular,  necessitating  dilatation  by  incision, 
was  quite  common.  Yet  the  very  ill  effects  which  have  led  to  its 
almost  complete  abandonment  have  also  taught  us  its  superior  advan- 
tages under  proper  indications.  A  cervix,  which  is  .soft,  flabby,  eroded, 
and  granular,  its  canal  patulous,  pouring  forth  profuse  muco-purulent 
secretion — a  condition  found,  for  the  most  part,  in  multiparae — is  greatly 
benefited  by  the  application  of  the  crayon  of  silver  nitrate  (5  per  cent, 
chloride)  to  the  whole  diseased  surface,  at  first  about  once  per  week, 
afterward  at  longer  intervals.  The  secretions  diminish,  the  erosion 
heals,  the  canal  contracts,  and  the  cervix — although  perhaps  slightly 
lacerated,  not  so  much  as  to  require  tracheloplasty — resumes  its  normal 
shape.  The  intervals  need  no  local  interference  save  the  use  of  the 
vaginal  douche.  The  number  of  applications  is  determined  by  the 
progress  in  each  individual  ca.se,  the  utmost  caution  being  observed  to 
discontinue  their  u.«e  before  the  seeming  necessary  contraction  has  been 
reached,  for  this  effect  is  continued  far  beyond  the  last  one.  Further 
treatment,  if  neces.saiy,  may  be  continued  with  iodine,  the  glycerol  of 
tannin,  or  boro-glyceride. 

A  flexible  silver  probe  of  curve  suitable  to  pass  through  the  cervical 
canal,  dipped  into  the  fused  nitrate,  after  the  manner  of  Sir  Benjamin 
Brodie,  may  be  substituted  for  the  crayon. 

Solutions  of  the  nitrate  (grs.  xx-lx  to  oj)  are  less  injurious  than 
the  solid,  in  mild  ca.ses  equally  efficacious.  The  weak  solutions 
are  adapted  to  more  irritable  forms  of  erosion,  and  the  stronger  to 
the  more  sluggish.  Solutions  are  to  be  preferred  when  granulations 
are  very  vascular. 

Solutions  of  the  chloride  of  zinc  (9j-9iij  ad  sj)  will  be  found  quite 
efficacious  at  times. 

Nitric  acid,  a  more  potent  caustic  than  the  silver  nitrate,  though  not 


566       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

more  painful,  and  less  apt  to  be  followed  by  hemorrhage,  is  adapted  to 
conditions  similar  to  the  above  and  the  more  rebellious  forms  of  catarrh 
of  the  Nabothian  follicles.  After  its  use  with  the  cotton-wrapped  appli- 
cator the  vagina  needs  to  be  protected  by  a  tampon  of  cotton  wet  with 
glycerin  or  oil  placed  against  the  cervix.  The  eschar  formed  separates 
in  from  a  week  to  ten  days,  and  leaves  a  granulating  surface.  Nitric 
acid  ought  not  to  be  reapplied  at  intervals  shorter  than  one  month,  the 
choice  of  time  being  one  week  after  the  close  of  menstruation. 

Acid  nitrate  of  mercury  has  nothing  to  recommend  it  above  nitric 
acid,  and  its  use  is  open  to  the  grave  objection  of  the  possibility  of 
inducing  salivation  through  its  general  absorption. 

Chromic  acid,  deliquesced  or  with  an  equal  part  of  water,  is  an 
efficient  caustic,  comparatively  painless,  safe,  and  not  liable  to  induce 
secondary  contraction  and  cicatrization.  It  too,  in  full  strength,  need 
not  be  applied  more  often  than  once  a  month,  although  weaker  solutions 
(3j  ad  §j)  can  be  used  once  a  week. 

All  these  more  active  caustics  should  generally  be  reserved  for  the 
more  severe  forms  of  the  disease  which  after  long  standing  have  resisted 
a  milder  course  of  treatment.  The  tendency  of  the  gynecological  practice 
of  to-day  is  to  restrict  their  use  to  the  smaller  number.  The  aim  of 
the  physician  should  be  to  make  the  local  management  as  mild  and  as 
painless  as  practicable.  As  the  disease  is  one  depending  upon  or  result- 
ing in  debility  and  nerv^ous  derangement,  the  practitioner  will  avoid,  if 
possible,  irritating  agents  and  painful  measures,  which  have  a  depress- 
ing effect  on  the  system  at  large.  Caustics  have  heretofore  been  used 
too  extensively,  and  there  has  been  a  lack  of  j  udgment  in  the  selection 
of  agents  of  this  kind  which  would  not  have  been  tolerated  in  local 
treatment  elsewhere.  The  best  results  are  frequently  obtained  by  an 
occasional  change  in  the  choice  of  application.  As  no  one  agent 
answers  all  cases,  so  no  one  can  be  depended  upon  during  the  whole 
period  of  management.  The  local  condition  left  after  cauterization 
may  be  much  improved  by  astringents  or  stimulating  alteratives. 
Astringents  in  time  lose  their  effect,  and  should  be  supplanted  by 
emollients,  etc. 

Many  of  these  topical  applications  referred  to  do  not  require  to  be 
followed  by  any  special  rest  on  the  part  of  the  patient.  With  perfect 
safety  they  may  be  made,  if  convenient,  at  the  physician's  office.  But 
all  caustics  of  the  more  active  kind  ought  to  be  applied  not  only  at 
the  patient's  residence,  where  she  can  take  the  necessary  rest,  but  cau- 
tion demands  that  she  maintain  the  same  for  several  days  in  addition, 
until  all  irritating  effects  have  passed  away. 

Chronic  cervical  endometritis  engrafted  on  a  laceration  of  the  cervix 
may  be  bettered,  but  cannot  be  permanently  relieved,  by  topical  medi- 
cation, if  the  rent  is  bilateral  or  multiple,  and  to  within  the  fibrous 


CHRONIC  CERVICAL   hWDOM/.TlHTIS.  r,t',7 

tissue,  ami  there  is  ever>i<)ii.  l'i(i;;ress  in  the  iiii|)i-r)\-enieiit  will  eoii- 
timie  to  a  eertaiii  jxiint,  then  cease,  and  as  surely  relapse  ii|>i»ii  >ii— 
pension     of    the    treatment.       Traehelo[)lasty    is    tiic    one    ne<'essarv 

Allusion  has  heen  made  to  the  utility  and  ne^'essitv  ot"  sueh  eau.-ties 
iLs  nitric  acid  and  chromic  acid  to  tlu'  <'ervical  canal  in  old,  rehellious 
catarrhs  dependent  on  exce-sive  and  persistent  secretion  of"  the  Nalxjtli- 
ian  follicles.  Xot  only  do  the  mild  caustics  utterly  fail  to  effect  anv 
favorahle  chant:;e,  but  even  these  potential  caustics  freipiently  prove 
inadetjuate.  Under  tiiese  circumstances  the  plan  re<;ommende<  1  l)\- 
Sims  should  be  jiractised.  After  dilatation  of  the  t"anal  with  a  tent, 
the  follicles  and  irranulations  are  thor(Mi<ihly  scraped  down  to  healthv 
tissue  with  the  sharj)  steel  ctu'ette,  after  which  the  actual  cautery  or 
Paquelin's  thermo-cautery,  a  little  above  black  heat,  is  run  over  the 
whole  surface.  .V  second  application  may  be  needed.  The  potential 
caustics,  after  curettinj;,  would  answer  much  the  same  purpose  as  the 
actual  cautery.  Dr.  Isaac  E.  Taylor,  from  a  considerable  experience, 
rejjorts  favorably  concerning  this  practice.  Thomas  gives  the  use  of 
the  sharp  curette  in  these  cases  his  earnest  indorsement.  Although 
the  risk  is  small,  the  operation  ought  to  be  followed  by  necessarv 
rest.  The  greatest  objection  that  can  be  urged  against  it  is  the  possi- 
bility of  subsequent  constriction  of  the  canal.  But  so  eifectual  are 
these  procechires  that  cases  which  hitherto  have  been  considered  incur- 
able may  be  made  perfectly  amenable  to  treatment.  Xot  onlv  Avill 
good  follow  the  excision  by  the  knife  or  scissors  of  exuberant  granula- 
tions from  around  the  os  and  cervical  canal,  but  it  is  a  j)roceflure  calcu- 
lated to  abridge,  to  great  degree,  the  course  of  other  local  treatment. 
Excessive  enlargement  of  the  cervical  glands — raucous  polvpi — is  to  be 
treate<l  by  abscission,  and  in  certain  cases  exsection  of  hvpertrophied 
and  projecting  tissue  may  be  similarly  dealt  with. 

May  local  treatment  to  the  diseased  cervix  and  canal  l)e  carried  on 
during  pregnancy?  "With  proper  precautions  and  due  care  avc  answer 
the  question  in  the  affirmative.  Most  of  the  accidents  in  the  induction 
of  abortion  by  local  interference  have  arisen  from  a  neglect  to  investi- 
gate and  determine  the  condition  of  the  body  of  the  uterus,  and  ascertain 
whether  it  may  have  been  gravid.  Pregnancy  aggravates  chronic  cer- 
vical endometritis,  in  that  it  increa.ses  the  catarrh,  the  granular  degen- 
erati<)n,  the  secondary  vaginitis,  and  pruritus.  By  the  gentle  use 
of  warm  vaginal  injections  of  a  uniform  temperature,  and  bv  the 
topical  use  of  astringents  and  emollients — in  rarer  ca.ses  the  nitrate 
of  silver  in  S(»lution — not  only  may  the  jiatient  be  made  more  com- 
fortable through  an  improvement  in  the  local  disease  and  the  arrest 
of  reflex  disorders,  as  nausea  and  vomiting,  but  parturition  itself  be 
made  easier. 


568       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

Bibliography. 
Battey,  Robert  :  A  m.  Gynecolog.  Transac,  vol  iv.  p.  55  et  seq. 
Bennet,  J.  H. :  Inflammations  of  the  Uterus,  1861. 
Championnieke,  Courty,  and  Leopold:  Am.  Journ.  Obsiet.,  vol.  xvi.  p.  1009  et  seq.; 

Non-Puerperal  Pelvic  Lymphadenitis  and  Lymphangitis,  Paul  F.  Mxjnde. 
Emmet,  T.  A.:  Priiiciples  and  Practice  of  Gynecology,  1884. 
Meigs,  Charles  D.  :  Diseases  of  the  Neck  of  the  Uterus,  1854. 
MuNDE,  Paul  F.  :  Minor  Surgical  Gynecology,  1885. 
Paget,  Sir  James  :  Clinical  Lectures  and.  Esssys,  1875. 
Ringer,  Sidney  :  Handbook  of  Therapeutics,  1880. 
Sims,  J.  Marion  :  Am.  Gynecolog.  Transac,  vol.  iv.  jip.  63,  64. 
SussENDORP,  G.  E. :  American  Journal  Obstetrics,  vol.  vii.  p.  473. 
Taylor,  Isaac  E.  :  Am.  Gynecolog.  Transac,  vol.  iv.  pp.  64,  65. 
Thomas,  T.  Gaillard  :  Treatise  on  the  Diseases  of  Women,  1880. 
Trousseau  et  Pidoux  :  Traite  de  Therap. 
West,  Charles  :  Pathological  Importance  of  Ulceration  of  the  Os  Uteri,  1854. 

CHRONIC    GENERAL    ENDOMETRITIS    AND    CHRONIC    CORPOREAL 
ENDOMETRITIS. 

Definitions  and  Synonyms. —  Chronic  corporeal  endometritis 
signifies  a  chronic  inflammation  of  the  mncous  lining  of  the  uterus  above 
the  OS  internum.  General  endometritis  signifies  that  the  cavity  of  the 
cervix  is  also  implicated. 

Corporeal  endometritis  and  general  endometritis,  localized  for  the 
greater  degree  in  the  corporeal  cavity,  are  recognized  by  the  names  of 
chronic  uterine  catarrh,  leucorrhoea  or  blenorrhcea,  internal  metritis, 
fundal  endometritis,  etc. 

Frequency. — Here  there  has  been  the  greatest  conflict  of  authority. 
The  utmost  extremes  of  opinion  have  been,  and  are  even  now,  enter- 
tained. With  the  views  of  Bennet  the  profession  is  well  acquainted. 
With  him  the  neck  of  the  uterus  was  the  favorite,  the  almost  exclusive, 
seat  of  chronic  inflammation.  Tyler  Smith  denied  the  existence  of 
chronic  corporeal  endometritis.  On  the  other  hand,  Aran  and  West 
contended  that  the  mucous  membrane  of  the  uterine  body  is  more  fre- 
quently the  seat  of  disease  than  that  of  the  neck.  Hennig  concurs  in 
this  view,  and  also  believes  in  the  frequent  existence  of  Fallopian 
catarrh.  Tilt,  an  authority  equally  good  with  Bennet,  his  associate 
at  one  time  in  practice,  radically  dissents  from  the  opinions  of  that 
distinguished  gynecological  pioneer.  Klob,  whose  expressions  on  such 
matters  are  entitled  to  the  greatest  respect,  describes  the  disease  as  of 
frequent  occurrence. 

Most  modern  authorities — Bernutz,  Courty,  C.  Braun,  Scanzoni, 
Schroeder,  Fritsch,  Atthill,  Barnes,  Eouth,  Play  fair,  Simpson,  Hart 
and  Barbour,  Edis,  Thomas,  Goodell,  and  Byford — now  recognize  the 
corporeal  form  of  chronic  endometritis,  either  as  a  distinct  entity  or  in 
the  form  of  general  endometritis.  There  is,  however,  a  great  variety 
of  opinions  among  these  as  to  the  relative  frequency  of  the  two  diseases. 


ciiiiosic  (ii:si:i:AL  r.sDoMirnnris.  5C0 

V\\v  aiitlior  (;ik('s  tlic  pusitimi  tliiU  Ixiili  clinicMl  mikI  |iii-t-ni<>r(cin 
cvidciKC  prove  tluit  ('(ii-ixtifMl  ciKloiiicli-itis  may  exist  as  a  di^tiix't  and 
wi'lI-tU'liucd  allc'ctioii,  like  thai  kindred  one  of  the  eerviea!  canal.  If 
CJirofiil  search  is  made  in  Ixulies  tliat  ha\'e  die(|  fioni  otlier  diseases, 
aeiite  and  chronic,  it  is  believed  that  nnmistakalde  evidences  will  he 
lound  ot'  its  existence.  In  onr  [)resent  state  of  knowledge  of  endomet- 
rial diseiLses  it  is  safe  to  tussunie — 

1st.  InHamination  of  the  tvrvieal  nuK-ons  memhrane  is  hy  far  the 
most  fre(iuont  of  all  the  chronic  forms  of  the  disease. 

2d.  General  endometritis  stands  second  in  the  order  of  frequency, 
and  is  laro-ely  confined  to  the  mnltiparie. 

3d.  Corporeal  endometritis,  the  least  frequent,  is  nevertheless  a  much 
more  common  disease  than  has  usually  been  accepted.  Generally,  it  is 
confined  to  the  nnllij)arfe.  Its  recognition  explains  many  cases  of  rebel- 
lions IcucorrliLca,  menorrliagia,  dysmcnorrhcca,  and  sterility. 

There  seems  no  good  reaiion  for  recognizing  fundal  endometritis  a.s  a 
distinct  form  of  the  aifeetion.  Its  symptoms  are  not  characteristic,  and 
it  probably  never  exists  independently  of  a  similer  condition  of  the 
remaining  corporeal  and,  it  may  be,  the  Fallopian  mucous  membrane. 

Pathological  Anatomy. — Like  chronic  inflammation  of  the  cer- 
vical mucous  membrane,  corporeal  endometritis  is  essentially  a  glandu- 
lar disease.  In  recent  cases  post-mortem  appearances  show  the  mucous 
membrane  hyjierremic,  swollen,  soft:,  and  succulent.  Pigment-streaks, 
brownish  or  blackish  in  color,  resulting  from  blood-extravasations,  are 
found.  At  first  the  tissues  are  quite  red,  while  later  they  become  gray- 
ish. The  surfaces  are  either  smooth,  papillary,  or  uneven,  especiallv 
on  the  fundal  and  posterior  walls,  and  covered  with  secretions.  The 
gland-t)penings  are  quite  visible,  the  cavity  dilated.  The  hypersecretion 
is  clear,  in  consistency  thin  and  in  reaction  alkaline.  It  contains  the 
chlorides.  It  may  be  brownish  and  bloody,  and  after  longer  duration 
muco-purulent  or  purulent.  Granulations  small  in  size  or  like  villous 
or  pf)lypous  masses  are  seen  covering  the  surfaces. 

In  old  cases  still  more  important  anatomical  changes  are  noticeable. 
The  mucous  membrane  is  eroded — a  desquamation  and  destruction  of 
the  peculiar  ciliated  epithelium.  Its  pi-esencc  is  replaced  by  polymor- 
phous cells  with  a  pavement-like  epithelium.  The  whole  membrane, 
the  utricular  glands  included,  now  becomes  smooth,  thin,  and  atrophied. 
A  layer  of  connective  tissue  lines  the  cavity,  covered  only,  perliaps,  by 
polymorphous  cells,  or  the  membrane  within  which  are  minute  cysts 
of  degenerated  glands  may  be  transformed  into  a  callous  structure  of 
varying  thickness.  The  glands,  however,  before  undergoing  general 
atrophy,  quite  commonly  take  on  cystic  degeneration  from  a  constric- 
tion or  localized  atrophy  of  their  orifices,  resulting  in  retention  of  tlieir 
contents.     Their  ajipoarance  is  that  of  rounded,  hemis]iherieal  projec- 


570       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

tions  or  pedunculated  tumors,  varying  in  size  from  a  pinhead  to  a  large 
pea,  elastic  to  touch  and  with  transparent  contents.  These  glands  may 
likewise  be  greatly  hypertrophied — cystic  or  glandular  polypi.  Asso- 
ciated with  the  above  conditions  are  the  so-called  vegetations,  granula- 
tions, or  fungosities.  They  resemble  somewhat  papillary  ejjithelioma, 
and  may  degenerate  into  that  condition.  Also,  there  may  be  detected 
pit-like  depressions  and  elevations  formed  by  a  rujDture  of  or  fall- 
ing out  of  the  glands.  Their  presence  may  lead  to  the  formation  of 
adhesions  and  the  subsequent  development  of  hydrometra  and  hsemato- 
metra.     Chronic  metritis  is  a  frequent  complication. 

General  endometritis  presents  more  or  less  of  the  foregoing  patholog- 
ical lesions,  in  conjunction  with  those  of  the  cervical  canal  already 
described. 

Etiology. — The  causes  are  of  two  kinds — predisposing  and  ex- 
citing. 

A.  Predisposing  Causes. — Among  these  prominently  rank  the  various 
diatheses  and  cachexise — scrofula,  tuberculosis,  syphilis,  aneemia,  leu- 
kaemia, haemophilia,  malaria,  rheumatism,  gout,  herpes,  etc.  The 
strumous  and  phthisical  diatheses  are  very  common.  Syphilis  acts 
as  a  cause  by  enfeebling  the  general  health  and  impoverishing  the 
blood. 

Corporeal  endometritis  occurs  at  all  ages,  from  the  beginning  of 
menstrual  life  to  old  age,  and  that,  too,  without  any  special  local 
exciting  cause.  Therefore,  the  best  evidence  of  the  operation  of  the 
predisposing  causes  is  afforded.  So  important  a  structure  as  that 
of  the  interior  of  the  uterus,  subject  periodically  to  changes  of  the  high- 
est physiological  hypersemia,  desquamation,  and  repair,  is,  above  most 
others,  especially  liable  to  receive  the  stamp  of  certain  general  morbid 
states.  Causes  acting  locally  may  be  wholly  inadequate  to  produce  the 
eifect  without  inherent  or  acquired  predispositions.  The  local  disease 
is  at  times  the  only  expression  of  the  latent  but  existing  constitutional 
taint. 

B.  Exciting  Causes. — Chronic  endometritis  is  a  very  frequent  sequela 
of  acute  endometritis  occurring  from  whatever  cause,  either  in  the  par- 
turient or  non-gravid  uterus.  After  parturition,  as  a  result  of  the  non- 
recognition  of  the  disease,  want  of  proper  or  sufficient  attention  thereto, 
some  vice  of  constitution,  or  too  early  resumption  of  the  erect  posture, 
a  very  large  proportion  of  the  cases  of  acute  endometritis  are  imper- 
fectly recovered  from  and  the  chronic  aifection  becomes  established. 

Endometritis  originating  within  the  area  of  the  placental  site  must 
be  recognized.  The  return  of  this  special  area  after  parturition  or 
abortion  to  its  original  size  and  state  is  often  delayed  and  imperfect. 
Retention  of  hypertrophied  decidua  and  young  placental  masses  at  or 
about  the  third  month   of  utero-gestation,   with,   it  may  be,   partial 


CHRONIC  GEyERAL   EXnn.VirriHTfS.  571 

«)i"i:;iiii/.at ii)ii  ol'  ilic  siiinc,  Icaxcs  the  interior  of  the  nlcriis  :i.<  a  roii^^li, 
raw-like  siirCaee,  secret iiiii:  iiuied-pus,  and  (he  soiii-ee  of  a  ])ersi>fent 
saiiLi'uiiH'oiis  (liscliaruc.  The  siirroiindiiiu-  pareiichv  iiia  is  thickened  and 
vascniar — iinpert'ecl  iiixdhil  ion.      (  'hi-onic  eiiildiiicl  ritis  snper\'eiies. 

IJennet  hiniscll'  expresses  the  jK)Ssihility  ol"  coi'poreal  endometritis  as 
the  result  ol'  the  leniithened  existence  of  inllaniniator\'  disea>e  of  the 
cervix.  Chronic  vaiiinitis  may  e\-enliiate  in  chi-onic  endoniitritis. 
(^hi'onic  p(>lvic  j)eritoiiitis  and  sal|)in<:itis  may  have  a  similar  hnt 
downward  course.  Wni  specilic  inllammation,  startinti;  in  the  vatiina, 
is  intlnitcK'  a  moi'e  lre(|neiit  cause  of  chi-onic  cndoineti'itis.  Xoeut^d'ath 
lias  drawn  the  attentit)n  of  the  protession  to  the  fre(|uency,  insidious- 
ness,  and  serious  conse(][Ucnces  of  what  he  terms  "  latent  ^'oiKtrrlujea 
in  the  female."  Although  some  of  these  views — secmintily  exti'eme — 
as  to  tlu>  prevalence  of  clironie  o;onori']ioca  in  women,  taken  from  hus- 
bands who  previously — it  may  he  many  years — have  had  the  disease, 
are  not  substantiated  by  others,  nevertheless  Dr.  Xoeuu'crath  has  invited 
a  jii'ofessional  interest  in  a  matter  of  the  deepest  concern,  involving  the 
lu'alth  of  women  and  their  fertility.  This  much,  at  least,  seems  con- 
elusive  :  Chronic  gonorrhoea  in  the  male,  supposed  to  have  been  cured, 
often  is  not  so.  Its  insidious  lurking  in  the  male  is  a  fruitful  source 
of  chronic  uterine  catarrh  in  women  previously  healthy.  This  catarrh 
resides  in  the  upper  uterine  cavity,  is  very  stubborn,  often  incurable, 
and   is  the  cause  of  2)ermanent  sterility. 

Anotlier  cause  of  corporeal  endometritis  is  enforced  sterility.  Xaturc 
seems  to  have  designed  that  the  internal  genitalia,  through  the  influences 
of  pregnancy  and  lactation,  should  have  stated  periods  of  change  and 
rest.  The  ever-repeating  periodical  influxes  of  blood  to  these  organs, 
month  after  month  for  many  years  of  married  life,  together  with  the 
turgescence  of  the  vessels  inseparably  incident  to  coitus,  aggravated  bv 
such  means  as  are  employed  to  prevent  impregnation  and  thwart  gesta- 
tion, are  sooner  or  later  inevitably  folloAved  by  their  evil  consequences. 

An  important  influence  which  produces  this  affection  is  obstruction 
to  the  escape  of  the  natural  secretions,  menstrual  and  otherwise.  These 
obstructions  are  formed  (a)  at  the  os  externum  from  congenital  mal- 
formations of  the  cervix — the  elongated  and  conoid  cervix — and 
ac(|uired  strictures,  usually  following  the  vicious  use  of  certain  caus- 
tics ;  (6)  at  the  os  internum  from  flexion.  The  cavity  above  the 
obstruction  becomes  dilated  by  distension  from  accunndation.  The 
uterus  is  provoked  to  j^ainful  contractions  to  cmjity  itself.  The  retained 
secretions  decompose  and  are  transformed  into  irritating  mattei"s.  Thus, 
in  consequence  of  distension,  septic  accumulation,  and  abnormal  con- 
tractions, the  mucous  membrane  above  the  point  of  obstruction  becomes 
inflamed.  Finally,  chronic  uterine  catarrh  is  provoked,  aggravated, 
and    perpetuated    by    lacerations    of  the    cervix,   chronic    congestions. 


672       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

displacements  of  the  whole  organ.  The  recognition  of  these  causes^ 
when  existing,  may  be  the  keynote  to  the  successfnl  management  of 
the  disease. 

Symptomatology. —  General  Symptoms. — There  is  the  greatest  di- 
versity of  symptoms  in  diiFerent  cases.  The  disease  may  continue  for 
several  years  with  prominent  local  symptoms,  yet  the  general  health 
seemingly  remains  good.  Again,  the  greatest  general  disturbance  in  kind 
and  degree  may  be  present.  The. tendency  of  the  aifection  is  to  grad- 
ually undermine  the  general  health — for  the  patient  to  lose  weight  and 
strength,  to  become  ansemic  and  annoyed  with  sympathetic  disorders 
of  digestion,  circulation,  and  innervation.  All  the  reflex  symptoms 
are  more  decidedly  manifested  than  in  cervical  disease.  Chief  among 
these  are  those  of  the  nervous  system — cerebral,  spinal,  and  ganglionic. 

Cephalalgia,  especially  on  the  crown  of  the  head,  of  a  burning  cha- 
racter, is  one  of  the  commonest  of  symptoms.  Attacks  of  migraine  at 
or  near  each  catamenial  epoch  are  frequent.  Then  there  is  hysteria  in 
its  protean  forms,  hystero-epilepsy,  catalepsy,  melancholia,  insanity,  etc. 
In  rarer  instances  there  are  paralyses,  amaurosis,  dyspnoea,  palpitation, 
cough,  aphonia,  and  the  various  vaso-motor  neuroses.  Certain  neur- 
algias, facial,  spinal,  intercostal,  etc.,  are  very  often  experienced.  Dis- 
orders of  the  skin  and  its  appendages,  pigmentations  on  the  forehead 
and  face  like  those  seen  in  pregnant  women,  hypersesthesia  or  anaes- 
thesia, loss  of  hair  or  change  in  its  color,  are  also  at  times  present. 

The  digestive  system  seldom  escapes  unaifected.  The  appetite  is 
impaired  and  capricious.  There  may  be  nausea  and  vomiting,  espe- 
cially at  the  approach  of  menstruation  ;  also  gastralgia,  flatulency, 
diarrhoea,  or  constipation.  The  urine  may  be  turbid,  loaded  with 
urates  or  phosphates ;  more  often  there  is  an  abundance  of  clear,  pale,, 
limpid  urine,  deficient  in  salts. 

Now  and  theu  the  general  symptoms  simulate  very  closely  those  of 
pregnancy.  Thus  there  are  nausea  and  vomiting,  enlargement  of  the 
abdomen  from  flatulency,  pain  and  tenderness  in,  and  enlargement  of, 
the  mammary  glands.  If,  in  addition,  there  should  be  menstrual  irreg- 
ularity of  the  form  of  amenorrhoea  and  the  uterus  be  enlarged,  an  error 
in  diagnosis  is  easily  committed.  Tilt  has  regarded  the  presence  of  the 
signs  of  pregnancy  in  young  women  without  menstrual  suspension  as 
prima  facie  evidence  of  internal  metritis. 

Various  explanations  have  been  oifered  for  the  condition  of  meteor- 
ism  so  often  and  prominently  exhibited.  Most  probably  it  is  a  reflex 
irritation  leading  to  paresis  of  the  nerves  governing  tonus  of  the  intes- 
tinal muscle,  and  consequent  accumulation  of  gas. 

Local  Symptoms. — The  first,  most  important,  and  most  constant  of 
all  the  local  symptoms  is  leucorrhoea.  Arising  solely  from  the  corpo- 
real cavity,  it  is  glairy  like  starch-water,  or  is  purulent  and  very  com- 


ciiiioMc  <:i:m:ii.\i.  i:si>nMi:TiiiTis.  r,i:\ 

moiilv  cominiiiLilctl  with  liluoil.  It  is  iicvcf  .-<»  tlii<'i<,  vi.-fid,  m-  tciia- 
rioiis  as  is  tlic  product  of  tlic  cervical  <ilaii(ls. 

BoiiiK't  i'('L>,ai'(l('<l  tlic  riisty-coloi'cd  Iciicori'lid'a — an  adinixtiirc  of 
blond  and  nuiciis — "a  diaractcristic  of"  iiitci-iial  metritis,  as  the  nisty- 
colort'd  I'xjK'ctoi'atioii  is  ul' jjuciiinoiiia."  Tliis  kind  of'discliar<;(!  mostly 
follows  tlio  menstrual  How,  l)iit  may  coiitimie  tliroiijili  the  month,  con- 
stitntinj;  meti'offha^^ia.  In  old  and  fchelliou^  cases  it  may  he  j)urelv 
])urid('nt.  The  (|uantity  is  always  increase<l  alter  iiieiistrnation.  In 
:uui?niic  snhjects  the  menstrual  How  may  consist  almost  entirely  of 
mncns  and  j)iis.  While  corporeal  lencoirh(ea  is  g'enerally  less  abundant 
than  cervical,  it  is  far  more  irritating  in  its  ])roj)erties.  It  often  pos- 
sesses such  acridity  that  the  va<iinal  and  vidvar  surfaces  look  red  and 
eroded — secondary  va<2;initis  and  vulvitis.  Thus  there  is  aggravating 
jM'uritus.  8nch  effects  are  by  no  means  in  j)roportion  to  the  amount 
of  the  catarrhal  discharge,  for  the  smallest  (juantity  may  be  the  source 
of  the  greatest  annf)vance.  There  is  but  little  doid)t  that  such  lencor- 
rlnea  is  cajiable  of  producing  urethritis  in  the  male. 

Notwithstanding  the  uterus  at  the  close  of  menstruation  is  disposed 
to  take  on  senile  involution  or  atrophy,  terminating  those  pericMlical 
congestions  which  tend  to  perpetuate  any  inflammatory  action  with  its 
catarrh,  the  morbid  processes  may  remain  indefinitely  from  the  direct 
force  of  the  disease  or  some  impediment  to  the  pelvic  venous  circula- 
tion. There  may  be  apparent  return  of  the  menstrual  flux  many  months 
after  its  function  has  been  supposed  to  cease.  The  cavity  of  the  uterus 
continues  to  throw  off  a  creamy  or  Avatery  discharge  of  special  acridity. 
This  is  chronic  senile  catarrh.  Barnes  states  that  in  a  considerable 
number  of  such  cases  he  has  found  more  or  less  complete  closure  of 
the  cervical  canal  in  some  of  its  ]iarts,  the  walls  having  grown  together 
by  a  process  comjDounded  of  inflammation  and  atrophy.  The  secretions 
continuing,  accumulate,  and  retention  ensues. 

Pain  is  a  very  uncertain  symptom.  Its  seat  may  be  the  back,  the 
hip,  or  the  uterine,  or  ovarian  region.  The  extent  of  pain  depends 
more  upon  the  amount  and  kind  of  complication,  as  chronic  metritis 
proper,  displacements  of  the  uterus,  perimetritic  inflannnation,  than 
upon  the  endometritis  itself. 

After  leucorrhoea,  the  next  most  constant  symptoms  refer  to  the  aber- 
rations of  menstruation.  Menorrhagia,  as  to  quantity,  time,  and  dura- 
tion, stands  first  in  order.  The  flow  appears  at  shortened  intervals,  is 
too  free,  or  prolonged.  Menorrhagia  may  be  merged  into  metrorrhagia. 
Another  feature  of  this  form  of  menstrual  disorder  is  an  interruption  in 
the  flow  :  thus,  afitcr  contiiuiing  for  a  few  days,  it  stops  for  a  day  or  so, 
to  return  again.  Profuse  and  dangerous  hemorrhages  sometimes  occur 
from  a  fungoid  condition  of  the  endometrium. 

The   opposite   menstrual    state,  amenorrhcea,   is    observable  usually 


574       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

only  after  a  long  duration  of  the  disease,  when  the  mucous  membrane 
has  become  smooth,  indurated,  and  atrophied. 

Dysmenorrhoea  in  some  variety — the  congestive,  from  a  hypersemic, 
swollen  endometrium ;  the  obstructive,  from  associated  stenosis  or  flex- 
ion ;  the  membranous,  from  an  exfoliation  of  the  entire  lining — occurs. 
By  most  authorities  this  shedding  of  the  membrane  in  dysmenorrhoea 
is  regarded  as  an  evidence  of  chronic  corporeal  endometritis. 

Sterility  is  present  in  the  majority  of  cases  of  endometritis  of  the  cor- 
poreal cavity,  whether  primary  or  secondary  to  stenosis  or  flexion,  for 
the  following  reasons:  1.  The  discharges  are  inimical  to  the  vitality 
of  the  spermatozoa.  2.  There  is  frequently  some  obstruction  to  their 
entrance  within  the  cavity,  because  of  stenosis  or  the  quantity  of  mor- 
bid secretions.  3.  Should  fecundation  take  place  there  is  an  inability 
to  retention  and  fixation  of  the  fertilized  product,  because  of  the  un- 
healthy endometrium.  It  is  easy  to  understand  how  a  smooth  surface 
or  one  covered  with  unhealthy  secretions,  a  dilated  cavity,  and  a  patulous 
internal  os  may  aflx»rd  a  poor  resting-place  for  the  ovum.  Or,  instead 
of  escaping  altogether,  the  ovum  is  stopped  only  at  the  inner  os.  Con 
cerning  this  point  Klob  has  well  remarked  as  to  the  predisposition  to 
the  occurrence  of  placenta  prsevia  in  females  who  have  suffered  for  a 
long  time  from  blenorrhoea  (uterine  catarrh).  Fertility  is  possible,  but 
not  probable.  Thus  every  function  of  the  uterus  is  deranged  in  this 
disease. 

Physical  Signs. — Patulousness  of  the  os  internum  from  a  relaxa- 
tion of  the  sphincter  at  the  isthmus,  increased  length  and  capacity  of 
the  corporeal  cavity,  tenderness  of  the  corpus  uteri  to  touch  and  biman- 
ual examination,  without  at  the  same  time  any  special  enlargement, 
great  sensitiveness  at  the  regions  of  the  os  internum  and  fundus  on  the 
application  of  the  sound,  with  a  tendency  to  bleeding, — these  are  the 
most  reliable  signs. 

Diagnosis. — This  is  determined  by  a  combination  of  the  symptoms- 
and  signs.  Localized  pain  and  tenderness,  the  presence  of  the  charac- 
teristic leucorrhoea  pouring  forth  from  the  uterus,  menstrual  disorders 
and  sterility,  associated  with  a  dilated  internal  os,  enlarged  corporeal 
cavity,  with  special  tenderness  therein  on  sounding,  are  the  evidences 
of  the  disease.  Not  all  of  these  are  noticeable  in  every  case.  In  many 
certain  symptoms  or  signs  may  be  wanting,  and  in  a  few  there  is  nothing 
save  the  leucorrhoea  to  excite  any  suspicion  of  the  nature  and  seat  of 
the  trouble. 

The  differentiation  between   cervical  and  corporeal  endometritis  is 

easily  determined  by  the  presence  in  the  former  of  the  characteristic 

cervical  discharge,   and   certain    special    local  signs   in  the  cervix  as 

revealed  by  touch  and  the  speculum,  and  their  absence  in  the  latter. 

General  endometritis  combines  the  symptoms  and  signs  of  both. 


cjmo.xic  <!i:si:iiM.  nsixiMiyniiTis.  rj7,> 

()ii('  rca~"'ii  \\\\\  iiillaiiimalinii  ol"  (lie  i-avity  of  tlic  titcriiic  hotlv  lias 
so  oitfii  |)a»t'<l  iiiirccdLiiiizcMl  is  tlial,  In-in^  ('(unplicat*'*!  witli  ctTviral 
disease  in  the  liinii  of"  liciieral  eiidoiiietritis,  tiie  jiraetitioiier  lias  satis- 
fied liiiiiseli'  with  what  he  sees.  Xoi  |)(ilia|»s  until  he  has  failed  to 
relievi'  his  |)atieiil.  allliiiii<:h  the  cervix  l»y  hical  treatment  presents  an 
iin|)foved    appeaiaiiee,  will    he    lie   di>|K»se<l    to   exphtre   Ijifther. 

( 'oMi'i.icAiioNs. — The  iii(»t  eoiiiiiioii  e(»ni|ilieatio!is  are  vaginitis, 
pruritus,  metritis,  iitei-iue  displacements,  and  Hexioiis.  Most  utero- 
ovarian  diseases  can  he  ti'aeed  to  the  inflaminations  of  the  endometrium. 

Pk()(;N(»sis. — Prognosis  depends  upon  the  extent,  duraticjn,  and  eoiu- 
plications  of  the  disease,  as  well  as  the  state  of  the  {general  health. 
A  lonu-standiuii-  j)urulent  catarrh  with  metritie  eonij)lieations  and  had 
general  health  })resents  a  very  unfavorable  pro;^nosis.  I3iJt  there  are 
many  eases,  less  severe,  which  are  quite  amenable  to  treatment.  Gen- 
eral endometritis  yields  more  readily  than  pure  corporeal.  In  the 
multii)ane,  caicris  paribus,  prognosis  is  more  favorable  than  in  the 
nulliparre.      Cases   of  gonorrhoeal  origin   are  especially  stubborn. 

Some  authorities  are  very  dubious  as  to  the  curability  of  this  disease. 
Scanzoni  is  often  quoteil  as  saying  that  he  cannot  remember  a  single 
case  cured.  Althouo-h  this  statement  convevs  a  more  srloomv  idea  in 
reference  to  the  prognosis  than  the  actual  facts  will  admit  of,  yet  it 
must  be  acknowledged  that  chronic  corporeal  endometritis  is  one  of  the 
most  intractable  affections  we  are  called  upon  to  treat,  and,  uncontrolled 
by  treatment,  it  has  an  indefinite  continuance,  manifesting  no  disposition 
to  abate,  until  at  the  menojiause,  with  the  suspension  of  the  menstrual 
function,  atrophy  of  the  uterus  ensues.  Xature  does  not  always  bring 
about  relief  even  at  this  time,  for  senile  catarrh  may  remain  for  nnun- 
years  longer  to  annoy  the  patient. 

Local  Treatment. — Having  diagnosticated  intracorporeal  inflam- 
mation, at  first  view  it  would  seem  wise  and  urgent  that  local  treatment 
be  instituted  here  in  the  same  manner  that  is  found  so  beneficial  for  the 
similar  disease  of  the  cervical  canal.  Further  reflection  on  the  function 
and  sensibility  of  the  inner  uterus,  and  especially  a  careful  review  of 
recorded  ex])eriences,  lead  one  to  undertake  such  treatment  not  only 
with  some  hesitation,  but  certainly  with  much  caution.  Bennet  has  con- 
tended that  the  cavity  of  the  uterus  proper  bears  surgical  interference 
less  than  any  other  part  of  the  organ.  Experience  shows  that  this  view 
is  correct.  Surprise  must  therefore  be  expressed  at  the  doctrine  ad- 
vanced by  Miller,  that  treatment  to  this  region  could  be  maintained  with 
as  much  familiarity  and  as  little  ap]irehension  as  to  the  uterine  neck. 

As  to  the  necessity  of  intra-uterine  treatment,  few  gynecologists 
doubt.  It  has  the  indorsement  of  most  modern  practitioners  in  this 
field  of  labor.  The  chief  questions  are:  AVhen?  In  what  cases"? 
How?  and,  What  are  the  agents  to  be  employed? 


576       THE  INFLAMMATORY  AFFECTIONS  OF  TtiE   UTERUS. 

Bennet  has  said  :  "  Internal  metritis  is  generally  'subdued  by  means 
adapted  to  cure  the  inflammation  of  the  cervical  canal  which  accom- 
panies it."  There  is  a  grade  of  truth  in  this  statement.  There  can  be 
no  doubt  that  corporeal  endometritis  of  limited  duration,  mild  in  cha- 
racter, coexisting  with  cervical,  may  be  subdued  by  attention  addressed 
exclusively  to  the  latter.  It  does  not  seem  reasonable  to  suppose,  how- 
ever, that  when  the  opposite  conditions  exist  any  material  or  lasting 
benefit  can  be  obtained  in  this  manner. 

The  testimony  of  so  acute,  careful,  and  experienced  an  observer  as 
Thomas  is  worthy  of  note.  He  says :  "  Observation  and  experience 
have  so  changed  my  own  practice  that  I  find  myself  very  rarely,  at 
present,  resorting  to  applications  above  the  internal  os."  Their  occa- 
sional necessity,  however,  he  does  not  deny.  Emmet  says  he  has 
abandoned  them  since  1879.  On  the  other  hand,  another  prominent 
and  skilful  observer,  Goodell,  always  carries  his  application  to  the 
fundus  whenever  the  internal  os  permits  it  to  pass.  By  so  doing,  he 
says,  he  has  obtained  better  results,  without  more  hazard,  than  when 
limiting  the  same  to  the  cervical  canal. 

Selection  of  Cases. — Practically,  in  management  three  kinds  of  cases 
may  be  recognized : 

1st.  Cases  of  chronic  corporeal  endometritis,  dependent  upon  and 
perpetuated  by  certain  morbid  constitutional  conditions  and  diatheses. 
Here  local  treatment  accomplishes  little  at  best — as  a  rule,  signally 
fails ;  in  fine,  in  many  instances  may  be  entirely  dispensed  with. 

2d.  Cases  in  which  the  corporeal  coexists  with  the  cervical  disease, 
both  arising  from  a  common  cause,  as  is  usual  after  abortions  or  partu- 
rition at  term.  Such  cases  are  limited,  for  the  most  part,  to  the  multi- 
parous  organ,  but  almost  always  show  a  greater  intensity  in  the  cervical 
region.  Local  medication,  addressed  solely  to  the  cervix,  will  often 
suffice,  the  disease  of  the  corporeal  cavity  being  arrested  through  the 
derivative  and  depleting  influences  of  the  agents  there  applied. 

3d.  A  class  of  cases,  considerably  less  frequent  than  the  last  men- 
tioned, in  which  the  disease  is  not  the  outcropping  of  a  diathesis,  and 
is  localized  to  a  point  above  the  internal  os,  or  if  coexistent  with  cer- 
vical disease  the  latter  is  secondary.  Here  cases  of  old,  well-pro- 
nounced menorrhagia,  metrorrhagia,  dysmenorrhoea,  and  metrorrhoea 
are  not  influenced  by  cervical  treatment.  The  indications  are  clear, 
and  the  necessity  for  the  execution  is  manifestly  imperative,  unless 
some  special  contraindication  presents  itself,  to  direct  the  local  treat- 
ment to  the  seat  of  the  disease. 

From  the  foreffoina;  classification  the  inference  is  that  the  number  of 
cases  absolutely  requiring  intra-uterine  medication  is  relatively  small. 

Under  all  circumstances  it  is  important  that  the  underlying  general 
and  local  condition  be  diagnosticated.      Sometimes   a  comparatively 


cjiJioMc  (;j:.\i:j:al  I'.SDoMiyrniris. 


'ill 


iMG.  188. 


small    local    Icsinii  or  almoniiity  ol"  llir  (•(  r\i\,  wliidi  i>  at  llic  hMllnin 
of  the   whole  (lilliciilly,  must    (iist    !»•   icmcclicd. 

The  Mrllmil. —  riici'f   arc,  in  uciici'al,  (wn  iiictliods    lor  the   iiitr<Mhic- 
(ioii   of  mctliciiial    aiiciits  within    the  ntcnis — int;-estioii  and   injection. 

A.  I  Ndl'.si'ioN. — {(i)  llji  flic  A/tji/!<'(((nr. —  I'l'ercrcnee  is  to  he  •riven 
to  the  instrument  ol'  hard  rnMier  or  \iri;in  >il\er  ( I'^itr.  1  •'^7  j,  made 
smooth,  slim,  tlcxihle,  and  with  an  olive-sha|)e<l  extremity. 
AI)S(»rl)ent  cotton  is  carelhlly  wrapped  ai'onnd  the  extremity 
in  t|nantit\-  siillielent  to  al)sorl>  an  adci|iiate  amount  of  tiie 
selected  tliiid,  and  yet  not  so  much  as  to  interfere  with  its 
passage  thronj^h  the  uterine  canal. 

To  secure  tiiorouglinoss  and  elHcieu(T  of  application  the 
followinii'  |)reliminary  ste])s  are  needed,  a  dis-       Fig.  187. 
reu'ard  of  which  is  the  chief  source  of  failure 
in  intra-ntei-inc  medication  : 

1st.  Free  exposure  of  the  cervix  by  means 
of  the  speculum,  choice  being-  given  to  Sims's, 
with  the  patient  in  the  left-lateral  semi-prone 
position,  the  cervix  being  steadied  with  the 
self- retaining  tenaculum. 

2d.  A  certain  amount  of  dilatation  of  the 
cervical  canal,  including  the  os  internum. 
The  disease  usually  does  this;  if  not,  it 
should  be  secured  by  a  tent  (tu]3elo)  or  ex- 
panding forceps.  The  latter  are  to  be  used 
gently,  and  never  expanded  to  the  full  width 
of  the  blades.  Dilatation  through  disease  or 
artificially  is  not  only  necessary  to  facilitate 
the  introduction  of  the  curved  cotton-wrap- 
ped applicator,  Ijut  also  to  prevent  the  medi- 
cating fluid  being  squeezed  from  the  cotton 
by  the  contracting  cervix. 

3d.  The  diseased  endometrium,  which  is  to 
receive  the  impress  of  the  medicament,  should, 
so  far  as  possible,  l)e  cleansed  from  all  secre- 
tions. Not  only  do  these  mechanically  ])re- 
vent  contact,  but  chemicallv  they  impair  the 

activity  of  most  agents.    With  the  nitrate  of      Applicator.  'v — y 

silver,  nitric  acid,  tannin,  iron  salts,  etc.  there  is  formed  an  ^xenmul^m '".r 
all>uminate.  Iodine  in  aqueous  (or  even  alcoholic)  solution  steadying  the 
undergoes  no  appreciable  change — a  feature  which  especially 
recommends  it  for  uterine  purposes.  The  removal  of  these  morbid  albu- 
minous secretions  is  effected  by  l)its  of  pure  cotton  or  sponge  squeezed  out 
of  hot  salt  water,  seized  in  a  small  jirobang,  bent  to  a  suitable  curve. 
Vol.  I.— 37 


578       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

All  gynecologists  have  experienced  the  difficulties  and  unsatisfactori- 
ness  of  applications  made  even  with  the  aforesaid  precautions  and  care. 
In  spite  of  our  best  efforts  a  certain  proportion  of  the  ingested  fluid  will 
likely  be  lost  by  the  contractions  of  the  uterine  walls  excited  by  contact 
of  the  irritant  introduced.  Thus,  surfaces  which  we  desire  to  medicate 
remain  partially  untouched,  and  portions  of  the  canal  not  diseased,  and 
of  course  not  requiring  medication,  receive  the  fluids.  Accordingly,  to 
obviate  these  difficulties  several  contrivances,  which  keep  the  cervical 
walls  asunder,  protect  its  canal,  and  afford  free  entrance  to  the  corpo- 
real cavity,  have  been  introduced.  Such  are  the  instruments  of  Lombe 
Atthill,  Peaslee,  Wylie,  Stoops,  and  others.  The  author  has  made  use 
of  one  fashioned  somewhat  after  the  pattern  of  Atthill's,  but  with  a 
fixed  flexible  handle  (Fig.  189).  The  canal  is  dilated,  if  necessary,  for 
the  introduction  of  the  canula ;  the  cavity  above  is  mopped  out  with 
sponge  and  probang;  the  rubber  applicator,  wrapped  and  saturated 
with  the  selected  fluid,  is  passed  to  the  fundus  and  allowed  to  remain 
a  few  seconds ;  finally,  the  applicator  is  withdrawn  to  within  the 
canula,  and  both  are  then  simultaneously  removed.  For  the  appli- 
cation of  the  stronger  fluid,  caustics,  nitric  acid,  chromic  acid,  etc.,  this 
instrument  is  very  valuable,  but  for  the  use  of  solutions  of  iodine  and 
carbolic  acid,  with  moderate  dilatation,  it  is  ordinarily  not  required. 

(6)  By  the  Apjdicator  Syringe. — This  is  a  method  obviating  some 
of  the  objections  and  difficulties  of  the  wrapped  applicator.  It  com- 
bines the  facility  of  injection,  as  well  as  the  safety,  for  the  most  part, 
of  ingestion.  It  was  first  employed  by  Lente ;  then,  soon  after,  but 
independently,  by  Munde.  It  consists  in  the  use  of  a  small,  tightly- 
fitting  syringe,  capacity  of  3ss,  with  graduated  piston,  to  which  is 
attached  a  long,  slender,  flexible  rubber  tube  for  introduction  through 
the  speculum  to  the  fundus  of  the  uterus  (Fig.  190).  The  syringe  is 
first  filled  with  the  fluid  to  be  ingested  ;  then  the  tube  at  its  extremity 
is  wrapped  with  cotton  in  a  manner  similar  to  the  applicator,  and  is 
next  introduced  within  the  uterus  to  the  fundus,  when  the  fluid  from 
the  syringe  is  gently  discharged  into  the  cotton  to  saturation.  It  is 
not  necessary  to  discharge  a  quantity  sufficifent  to  be  seen  oozing  from 
the  OS  externum.  A  saturation  of  the  cotton  (a  matter  which  can  be 
accurately  determined  by  previous  experiment)  implies  the  contact  of 
the  medicament  in  an  undiluted  state  to  the  endometrium.  If  care  is 
taken  not  to  inject  a  surplus  of  fluid  which  may  distend  the  uterine 
cavity,  no  more  unpleasant  results  need  follow  this  method  than  with 
the  simple  applicator. 

This  method  is  an  excellent  one  for  the  application  of  tincture  of 
iodine  and  carbolic  acid,  but  it  ought  not  to  take  the  place  of  the  pro- 
tecting canula  for  the  fluid  potential  caustics. 

Hegar  and  Kaltzenbach  have  made  use  of  applications  of  medicated 


en  IK  IS  ic  <;!■:. \ /■:/:. I L  nshoMKinrris.  579 

Fi(i.  1.S!». 


4  S  2  1 

Palmer's  Intra-uterine  ^red^cato^  :  1,  canula  for  protecting  the  cervical  cannl :  2,  plug  to  facili- 
tate introductiou  of  cauula;  3,  spunge-holder  to  cleanse  uterine  cavity:  4.  flexible  silver 
applicator. 


580        THE  INFLASniATOBY  AFFECTIONS  OF  THE   UTERUS. 

lint,  and  Sims  of  cotton,  by  means  of  his  slide  applicator  (Fig.  191). 
Such   applications    are  introduced  and  allo"\ved  to  remain  within  the 

Fig.  190. 


Applicator  Syriuge. 


uterus  for  from  twelve  to  twenty-four  hom's.  Doubtless,  thereby  more 
decided  and  permanent  effects  are  secured,  for  not  only  is  the  medica- 
ment left  in  contact  with  the  diseased  surface  for  a  longer  period  of 


Fig. 191. 


Sims's  Applicator,  with  slide. 

time,  but  the  uterus  is  made  to  contract  by  the  presence  of  a  foreign 
body. 

Fluids  used  by  Ingestion. — These  are  solutions  of  iodine,  chloride 
of  zinc,  nitrate  of  silver,  carbolic  acid,  chromic  acid,  and  nitric  acid. 
Of  these,  iodine  in  the  form  of  Churchill's  tincture  is  one  of  the  most 
useful,  and  carbolic  acid  stands  next.  Iodine  is  stimulant,  alterative, 
antiseptic,  and  haemostatic.  Carbolic  acid,  a  feeble  caustic,  is  one  of 
the  most  efficacious  and  safe  agents,  and  is  especially  adapted  to  the 
milder  forms  of  the  disease.  Playfair,  Thomas,  and  others  hold  it 
in  the  highest  esteem. 

Iodized  phenol,  a  combination  of  iodine  and  carbolic  acid,  first 
recommended  by  Battey  in  1877,  in  proper  strength  (1  part  iodine  in 
4  parts  by  weight  of  carbolic  acid),  is  a  most  excellent  agent.  Its  chief 
objection  is  its  disagreeable  odor.  Solutions  of  nitrate  of  silver  are 
more  irritant  and  less  useful  than  in  cervical  disease. 

Chromic  and  nitric  acids  are  reserved  for  the  severer  forms  of  the 
disease  with  patulous  canal,  granular  degeneration,  purulent  discharge 
— endometritis  villosa,  polyposa,  hyperplastica,  membranosa,  hsemor- 
rhagica — cases  which  probably  will  resist  less  active  treatment.  Nitric 
acid  in  its  pure  state,  so  highly  extolled  by  Atthill,  Kidd,  Kennedy, 
and  other  British  gynecologists,  is  not  so  painful  or  severe  an  applica- 
tion as  might  appear ;  nor  is  its  use,  within  proper  restrictions,  more 
dangerous  than  that  of  other  agents,  and  in  properly  selected  cases  it 
is  certainly  more  efficacious.     To  protect  the  cervical  canal  and  prevent 


ciiitoMc  (!i:sEiiM.  i:si><)Mi:rin'ns.  o>ii 

cicatricial  contraction  in  the  rc^iion  ol"  tlic  o>  cxlcrinini  the  cainila 
should    l)c   cni|)loyc(l    in    the   use  ol"  nitric  aci<l. 

(^irholic  acid  may  i)c  appliccl  once  in  f«»nr  t<t  live  days;  ( 'Inircliill's 
tincture  and  iodized  phenol,  ahoiit  once  a  week  din-in<r  the  menstrual 
interval;  the  stronger  acids  rarely  ol'tcncr  than  once  a  month.  Too 
fre([uent  or  inineeessary  use  ot"  nitric  acid  may  lead  to  cicatrization  and 
early  induration  of  the  endometrium. 

Solids  used  by  Ingestion. — Various  astrintrents,  alteratives,  and  caus- 
tics niav  l)e  incorporates]  with  lard  or  cocoa-butter  or  vaseline  in  the 
form  of  a  plasma  or  ointment,  and  be  ingested  by  means  of  a  syringe 
or  tube  with  piston.  This  is  a  favorite  method  of  intra-uterine  medi- 
cation with  Robert  Barnes  of  London,  Fordyce  Barker  and  F.  D. 
Lentc  of  New  York.  The  application  of  all  ointments  is  disagreeable, 
and  in  point  of  efficaciousness  they  rank  much  inferior  to  fluids. 

Instead  of  ointments,  medicated  crayons,  pencils,  suppositories,  and 
pastilles,  containing  carbolic  acid  (grs.  ij),  zinc  sulphate  (grs.  j-ij),  iodine 

Fig.  192. 


Applicator  Syringe  for  fluids  or  ointments. 

(grs.  j-ij),  and  iodoform  (grs.  iij-v),  have  been  used.  The  last-named 
remedy  is  higlily  recommended  by  Fordyce  Barker  for  the  menorrhagia 
of  the  climacteric  dependent  upon  endometrial  congestion.  Iodoform 
pastilles  make  sometimes  very  useful  applications  for  chronic  catarrh. 
These  pastilles,  properly  prepared  with  gelatin  coating,  flexible  for 
introduction,  yet  firm  enough  to  be  seized  with  a  speculum  forceps, 
possess  all  the  advantages  of  this  method.  Sometimes,  when  slow  in 
melting,  they  produce  symptoms  of  uterine  colic. 

Nitrate  of  silver,  in  the  solid  form  as  a  crayon,  has  frequently  been 
aiiplied  within  the  uterine  cavity.  Recamier  first  introduced  the  prac- 
tice, and  it  has  been  followed  by  Lallemand,  Bennet,  Courty,  Miller, 
Byford,  Lente,  and  others.  At  the  present  time  the  practice  has  gone 
almost  entirely  into  disuse.  Aside  from  the  danger  of  a  portion  of  the 
crayon  being  broken  oif  on  account  of  the  strong  contractioas  excited 
in  the  uterus,  the  application  itself  is  frequently  followed  by  the  most 
intense  pain.  Profuse  hemorrhage  and  peritonitis  have  likewise  ensued. 
Moreover,  the  practice  of  the  introduction  of  a  solid  stick  of  the  nitrate 
within  the  uterus,  allowing  it  to  remain  and  melt,  is  too  hazardous  to  be 
countenanced.  Occasionally,  very  little  or  no  pain  follows  this  treat- 
ment, probably  oAving  to  the  fact  that  the  stick,  floating  as  it  were  in  a 
puddle  of  secretions  of  mucus,  pus,  or  blood,  is  neutralized  by  them 


582       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

and  does  not  come  in  contact  with  the  endometrium.  It  is  a  well- 
established  fact  that  the  greater  the  dilatation  and  disease  of  the  corpo- 
real cavity,  the  more  tolerant,  coeteris  paribus,  the  organ  is  to  irritant 
medication  and  surgical  interference.  To  say  the  least,  the  solid 
nitrate  is  less  safe  than,  and  has  nothing  to  recommend  it  before, 
nitric  acid.  If  used  at  all,  the  method  of  application  of  fusing  it 
on  a  flexible  probe  is  to  be  preferred. 

Byford  states  that  he  has  frequently  effected  a  cure  in  endometritis 
complicated  by  stenosis  and  flexion  by  the  introduction  of  tents  of 
slippery  elm,  which  by  dilatation  overcome  the  constriction,  and  also 
by  pressure  exercise  a  salutary  influence  over  the  diseased  mucous  mem- 
brane. Each  tent  is  from  1-|— If  inches  long,  ^  inch  in  diameter — small 
enough  to  pass  through  the  narrow  canal. 

B.  Intra-uterine  Injections. — This  is  one  of  the  most  ancient  of 
gynecological  usages,  advised  and  practised  by  Hippocrates  some  twen- 
ty-two hundred  years  ago,  for  medicating  the  interior  of  the  uterus. 
Subsequently,  it  was  used  by  others  among  the  ancients,  and  later  on 
by  Ambrose  Pare  in  the  sixteenth  century ;  within  the  past  twenty  years 
it  has  been  quite  extensively  employed.  There  is  scarcely  a  therapeutic 
resort  so  old  or  one  which  has  passed  through  so  many  phases  of  prac- 
tice— ^to  be  forgotten,  revived,  then  rejected,  and  finally  reintroduced 
and  indorsed. 

If  the  healthy  uterus  be  injected  with  fluid,  the  following  symptoms 
will  probably  be  noticed :  Uterine  pain  and  colic,  abdominal  tenderness, 
feeble,  frequent  pulse,  coldness  of  the  extremities,  nausea  and  vomiting, 
and  other  indications  of  shock.  The  intensity  of  these  symptoms  will 
vary  according  to  the  quantity  and  force  of  the  injection,  the  character 
of  the  fluid,  and  the  special  susceptibility  of  the  person.  That  their 
occurrence  does  not  entirely  depend  upon  the  quantity  or  irritating 
character  of  the  fluid  is  evidenced  by  the  fact  that  at  times  they  are 
manifested  where  its  quantity  is  very  small  and  it  is  most  bland.  If 
the  uterus  is  diseased  with  chronic  inflammation,  these  symptoms  are 
apt  to  be  provoked  with  less  severity,  or  may  be  absent  altogether, 
according  to  the  size  of  the  cervical  canal  for  exit  of  the  fluid,  the  capa- 
city of  the  uterine  cavity  for  its  reception,  and  the  presence  of  various 
secretions  to  neutralize  the  injection. 

jSTumerous  reasons,  worthy  of  notice,  have  been  advanced  in  explana- 
tion of  these  morbid  phenomena  : 

1.  Penetration  of  the  Injected  Fluid  through  the  Oviducts  into  the 
Peritoneal  Cavity. — Many  experiments  at  difl^erent  times  have  been 
made  to  test  the  possibility  of  this  accident.  Vidal  first  operated  upon 
the  cadaver,  and  found  that  with  moderate  pressure  the  fluid  did  not  so 
enter.  Hennig's  experiments  coincided.  Klemm  could  make  the  fluid 
pass  through  the  Fallopian  tubes  oidy  on  great  pressure.     The  author 


ciiiiosK'  (ii:si:n.\L  i:\ix iMiyriiiris.  583 

has  r('|u'at('(lly  iiiadc  similar  cxpciiiMciifs  hy  constricting;  with  a  stout 
cord  the  cervix  around  a  tuhe  (ilted  to  a  stronj^' air-tight  syrinj^e.  No 
fluid  could  l)c  liirccd  throu<;h  the  o\i(hicts  uidoss  tliey  were  dilatcch 

1  ('  >uch  dilHcuhies  are  encountered  in  the  dead  suhject  where  then; 
is  no  iustinetix'c  contraction  oi'  the  >|)hinctei'  at  the  nieti'o-salj)ingian 
orifice,  how  much  lireater  will  he  those  met  with  in  the  li\inul  Now, 
do  intra-uterine  injectious  over  so  penetrate  in  tlie  liviujj;  suhject  ?  A- 
the  iitorus  wlieu  injected  is  usually  diseased  in  some  way  or  eontaius 
morbid  materials,  and  a.s  under  these  conditions  the  orifices  of  the 
orji^an  are  f'reciuently  dilated,  it  follows  that  in  a  cei-taiu  rare  j)roj)or- 
tion  of  cases  penetration  of  the  fluids  to  within  the  abdcjminal  cavity 
does  occur.  Post-mortem  examinations  and  Lawson  Tait's  opera- 
tion prove  the  existence  of  })atulous  and  dilated  tubes.  Von  Hasel- 
berg,  Barnes,  and  others  report  cases  where,  on  autopsy,  solutions  of  iron 
salts  were  found  at  the  fimbriae.  But,  notwithstanding  these  admis- 
sions and  provings,  evidently  the  symptoms  cannot  be  traced,  except 
possibly  in  rare  instances,  to  such  causes. 

2.  Penetration  of  the  Uterine  Veins. — An  impossibility  in  the 
healthy  uterus,  unless  under  the  influence  of  the  greatest  force,  but 
an  admitted  possibility  in  certain  morbid  conditions  of  the  organ. 

3.  Entrance  of  Air  into  the  Veins  and  General  Circulation. — Like- 
wise possible  when  the  mucous  membrane  is  exfoliated,  veins  are  en- 
larged from  disease,  pregnancy,  or  after  parturition  or  abortion.  The 
experiments  of  Klemm  tend  to  confirm  the  possibility  that  injected 
fluids  w^ith  a  constricted  cervical  canal  may  be  more  easily  driven  into 
the  venous  system  than  into  the  oviducts. 

4.  Acute  Inflammations  :  Peritonitis,  Phlebitis,  Endometritis. — The 
rapidity  of  the  occurrence  of  the  symptoms  precludes  the  acceptance 
of  this  explanation.  These  inflammations  do  often  occur  after  intra- 
uterine injections,  and  they  are  the  most  common  immediate  causes 
of  a  fatal  issue ;  but  such  lesions  are  not  the  direct  and  immediate 
cause  of  the  first  phenomena. 

5.  Rapidity  of  Absorption. — Certain  medicines,  as  solutions  of  iodine, 
carbolic  acid,  chromic  acid,  acid  nitrate  of  mercury,  etc.,  may  be  quickly 
absorbed  into  the  general  circidation  and  produce  evidences  of  poison- 
ing. Iodine,  applied  to  the  uterine  cavity  even  more  than  to  the  cervix, 
is  not  uncommonly  tasted  by  the  patient,  owing  to  its  rapid  absorption. 
A  denuded  mucous  surface,  large  and  superficial  blood-vessels,  greatly 
facilitate  this  action.  But  absorption  does  not  always  take  place,  and 
if  it  did  could  not  always  do  harm.  Violent  symptoms  may  supervene 
on  the  injections  of  pure  warm  water. 

6.  Shock. — The  uterine  cavity  in  a  healthy  non-gravid  organ  at  the 
non-menstrual  inter\  al  is  no  cavity  at  all.  In  normal  menstruation  it 
holds  but  a  few  drops  of  blood.     Only  wdien  diseased  by  some  morbid 


584       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

growth  or  accumulating  secretions  is  there  a  real  cavity.  Injection  of 
a  healthy  organ  is  attended  by  an  abrupt  separation  of  the  coaptating 
myalls — a  distension  of  the  cavity.  If  the  quantity  is  in  excess  of  a 
few  minims,  and  a  certain  portion  is  retained,  contractions  are  excited 
to  empty  the  uterus.  The  sudden  entrance  of  a  foreign  substance,  rapid 
distension  and  contraction,  imply  irritation  of  the  hypogastric  plexus 
of  the  sympathetic — shock.  This  is  the  most  plausible  theory,  under  all 
the  circumstances,  that  we  have.  It  is  the  only  tenable  one  to  explain 
the  phenomena  as  presented  in  healthy  subjects.  It  is  satisfactory,  too, 
as  showing  why  these  phenomena  are  less  severe  or  absent  when  the 
injection  enters  a  dilated  cavity,  mingles  with  morbid  secretions,  or 
readily  finds  an  exit. 

In  view  of  these  facts  various  precautions  can  be  observed  which 
tend  to  prevent  the  ill  effects  of  intra-uterine  injections : 

1.  Dilatation  of  the  Cervical  Canal. — Whether  this  is  the  result  of 
the  disease  or  is  accomplished  artificially  by  tents,  it  matters  not,  so 
that  the  injected  fluid  readily  flows  out  of  the  uterus,  retention  and 
distension  thereby  being  prevented.  For  manifest  reasons,  it  is  more 
dangerous  to  inject  the  uterus  when  flexed. 

A  ready  exit  of  the  current  is  also  secured  by  the  use  of  a  double 
canula.  There  are  a  number  of  devices,  as  ISTott's,  Byrne's,  Skene's, 
and  others.  The  one  used  by  the  author  since  1870  readily  permits  of 
a  reflux  current,  and  with  it  retention  with  distension  is  impossible. 
The  canula  is  fitted  to  an  air-tight  syringe  with  the  capacity  of  half 
an  ounce.     (See  Fig.  179). 

2.  Shock  is  diminished  by  using  fluids  at  a  temperature  of  at  least 

95°-98°  F. 

3.  Distension  and  shock  are  diminished  by  injections  in  small  quan- 
tities administered  slowly,  gently,  drop  by  drop. 

4.  The  possibility  of  injecting  air  is  prevented  by  using  a  perfect 
instrument  and  thoroughly  filling  it. 

By  an  observance  of  these  precautions  are  intra-uterine  injections 
safe  ?  Doubtless  by  them  the  dangers  in  a  large  degree  are  avoided ; 
consequently,  they  should  be  complied  with  in  all  instances  where 
resort  is  had  to  this  method  of  medication.  But  even  then,  with 
the  greatest  possible  care  and  precaution,  occasionally  uterine  pain  and 
colic,  symptoms  of  rapid  absorption,  with  subsequent  development  of 
metro-peritonitis,  etc.,  will  arise,  terminating,  it  may  be,  fatally.  There 
are  those  who  have  been  so  fortunate  and  skilful  as  to  have  encountered 
no  such  accidents  in  a  large  experience.  Authorities  in  high  position 
still  utilize  this  method  of  intra-uterine  medication,  but  a  verdict  made 
by  a  large  majority  of  gynecologists  of  to-day,  based  upon  accumulated 
personal  experience,  is  against  the  method  except  in  rare  cases.  Chronic 
endometritis  is  an  affection  not  of  danger,  but  largely  one  of  incon- 


runoMc  (:i:m:i:.\l  h.MxiMi/rniris.  r),sr> 

veniciicc.  In  its  inaiia<;('iiu'iit  no  pnictitioiuT  is  warranted  in  assiiniinj^ 
iimu'ccssarv  risks,  wliicli  tlu'si-  iiijwtions  imavoidahly  imply.  Mon;- 
over,  the  method  is  ordinarily  imneeessarv,  iiiasmueli  as,  even  if  safe, 
it  is  not  snperior  to  that   hy  inj^estion. 

What,  then,  are  tiie  eirenmstanees  in  w  hidi  intra-nterine  injections 
in  the  non-j^ravid  state  are  jnstifiable  and   WeneHcial? 

1.  Cases  of  threatened  or  aetnal  septiejemia  the  resnlt  of  deeonipos- 
injj  material  Avithin  the  uterns,  life  being  endangered].  Here  the  injec- 
tions, because  of  a  patulous  canal,  are  less  hazardous  than  usual.  Even 
if  as  dangerous  they  would  be  justifiable,  for  the  reason  that  the  prac- 
tice is  attended  with  less  risk  than  is  the  disease  unchecked. 

2.  Cases  of  uterine  hemorrhage  otherwise  uncontrolled. 

The  agents  used  for  septicaemia  are  solutions  of  carbolic  acid,  potassic 
permanganate,  and  mercuric  bichloride ;  for  hemorrhage,  hot  water,  hot 
vinegar,  tincture  of  iodine  pure  or  diluted  one  half.  For  the  latter  class 
of  cases  the  number  of  instances  in  which  injectioas  will  be  deemed 
neeessarv  must  be  very  small,  in  view  of  other  valuable  and  safe 
resources  at  hand. 

If  untoward  symptoms  unavoidably  arise,  they  are  to  be  met  by  the 
use  of  morphina  hypodermatically,  internal  stimidation,  and  external 
heat. 

The  curette,  judiciously  employed,  is  one  of  the  most  valuable  of  all 
our  therapeutic  resources  in  the  management  of  chronic  endometritis. 
Often,  its  use  should  precede  local  uterine  medication ;  it  may  render 
the  same  entirely  unnecessary,  and  not  nnfrequently  will  it  effectually 
control  conditions  of  the  uterine  cavity — endometrial  thickening,  soft- 
ening, and  granulations  attended  with  hemorrhage — which  topical  treat- 
ment of  any  kind  fails  to  relieve.  The  indications  for,  and  uses  of, 
this  instrument  will  be  referred  to  in  flill  under  the  subject  of  Uterine 
Fungosities. 

We  must  not  fail  to  remember  that  chronic  corporeal  uterine  catarrh 
may  be  not  only  started,  but  maintained,  by  a  cervical  laceration  or 
uterine  displacement,  and  to  cure  the  catarrh  we  must  remove  the 
cause. 

,  Contraindications,  Dangers. — Intra-uterinc  medication  of  any  kind 
by  ingestion  or  injection  is  contraindieated  when  the  uterus  or  the 
perimetritic  tissues  are  especially  tender.  Before  such  interference 
is  commenced  all  tenderness,  due  to  acute  congestion  of  the  uterus, 
or  lurking  inflammation  in  the  surrounding  cellular  or  [)eritoneal 
tissues,  should  be  removed  by  rest,  the  hot  douche,  saline  purgation, 
counter-irritation,  and  sedative  medication.  There  is  always  increased 
danger  of  exciting  a  new  attack  of  jierimetritic  inflammation — gener- 
ally peritoneal — in  every  instance  where  this  disease  has  previously 
existed,  although,  seemingly,  all  evidences  of  it  have  become  eflfiieed. 


586       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

Intra-uterine  medication  and  curetting  are  most .  decidedly  contrain- 
dicated  when  the  uterus  is  more  or  less  fixed  from  inflammatory  exu- 
dations and  adhesions. 

Intra-uterine  treatment  should,  at  the  commencement,  be  mild  and 
tentative,  in  order  to  test  special  individual  susceptibilities.  For  the 
same  reason  such  treatment  is  better  initiated  at  the  patient's  house. 
There  is  the  greatest  variation  in  point  of  sensitiveness  in  different 
patients.  With  some  the  least  interference  for  exploration  and  treat- 
ment excites  unexpected  disturbance ;  with  others  much  manipulation  is 
borne  without  any  unpleasant  symptoms.  When  the  menstrual  period 
is  impending,  the  nervous  and  vascular  systems  being  at  the  acme  of 
excitability  and  tension,  then,  above  all  other  times,  slight  causes  are 
capable  of  provoking  undue  reactions. 

Proper  precautions  as  to  the  time  of  applications,  exposure,  and 
exercise  afterward  should  be  observed  in  all  cases. 

The  question  of  intra-uterine  medication  is  one  of  the  most  import- 
ant and  serious  within  the  domain  of  uterine  therapeutics.  The  author 
has  endeavored  to  present  a  fair  status  of  the  subject  in  the  face  of 
accumulated  and  sifted  facts.  Amid  the  great  variety  of  opinions, 
apparently  based  upon  experiences,  the  beginner  is  put  at  a  loss  to 
know  what  course  to  pursue.  As  will  be  inferred  from  the  foregoing 
pages,  the  author  is  not  disposed  to  side  with  either  extreme  of  prac- 
tice— not  with  those  who  would  altogether  discard  intra-uterine  treat- 
ment or  with  those  who  adopt  it  in  all  cases  where  the  upper  cavity 
is  seemingly  diseased.  Truth  here,  as  elsewhere,  lies  in  the  middle 
ground.  Without  doubt,  immense  harm  has  been  done  and  many 
valuable  lives  have  been  sacrificed  by  injudicious  and  uncalled-for 
local  treatment.  That  it  has  been  used  too  frequently — used  to  be 
abused — is  freely  admitted.  That  it  can  be  omitted  in  not  a  few 
cases  in  which  formerly  it  was  deemed  necessary,  and  that  in  these 
cases  better  results  in  a  safer  way  can  be  obtained  by  other  methods, 
should  not  now  be  denied.  But  the  reaction  against  intra-uterine 
medication  has  probably  gone  too  far.  With  a  proper  selection  of 
cases,  and  with  due  restrictions  and  precautions,  intra-uterine  medi- 
cation is  of  great  service  in  many  cases — a  service  too  valuable  to 
be  laid  aside  and  ignored.  In  this  department  of  practice  most 
forcibly  does  it  behoove  us  that  in  our  efforts  to  do  good  we  do  no 
harm. 

Bibliography. 

Aran  :  Malad.  de  F  Uterus. 

Atthill  :  British  Med.  Journ.,  Jan..  1873. 

BarkeK  :   Transac.  Am.  Gynecolog.  Soc,  vol.  iv.  p.  67  et  seq. 

Barnes  :  Diseases  of  Women. 

Battey,  Robert  :  "  Intra-uterine  Medication,"  Am.  Gynecolog.  Transac.,  vol.  iv. 


ULCERATloys  AM)    l)i:<: IISEIIATIOSS   OF  CIHlVIX    rTKIll.     '>>*,! 

Bennkt:  Injlumiimtii)n  of  the  UUtum. 

Bkuni'TZ  AN'i)  (itHTPiL:  '' Diseases  of  Winneii,"  Tnuuvictium  uf  Sijili-nhim  Sur.,  1807. 

J^YKOKD:    Di.ifM'x  iif  W'liinin,  p.  1124  <'/  •'«■'/. 

Coi'inv  :    Midnd.  dr  /'  Utenin. 

lOnis  :   />('.'<c((.s('.s  o/'  W'oiiwn. 

Emmkt:   PrinripliH  (iiitl  Prdclirr  of  Cii/nccolDi/i/,  1884. 

FlllTscil :   Dm-hxim  i)f  Woiin-iiy  1883. 

(JooDKLL:    Lri<.foii.t  in  Giimrolixjij,  pp.  118,  11!). 

IIakI'  and  Hakrouk:   Munnd  of  (ji/iKrenlotfi/. 

Kamkui:r:  "Treatment  of  I'terine  C'atarrli,"  Am.  Jniirn.  Obntetrinf,  vol.  ii.  p.  18.5. 

Klou:    Piilliolo(/iral  AiKtlomi/  <;/'  J'Viiudf  Sfxiud  Ort/(ins. 

MiLLKR:  '' Ketrospei't  of  I'terine  Pathology,"  Am.  Journal  (JhiilelriiM,vo\.  iv. 

MuNDE:  7';v(;(.-«c.  Am.  Gi/nicoloi/.  Sue,  vol.  iv.  p.  71,  and  Minor  Siin/iad  (itjnecoloijij,  1885. 

NoKOGiCKATH :   "Latent  ( i(inonii<i';i   in   llii'   I'enuile  Sex,"  187.3;   also,  Tranmc.  Am. 

Gynfcoloy.  Soc,  1871), 
Nott:  "Treatment  of  Kndnnietiitis  liy  I'lerinu  Injections,"  Amer.  Jouriud  Ob.sli:l.,viA. 

ii.  p.  470. 
Playfair:  London  Lancet,  Jan.,  1873. 
Peaslee:  Xew  York  Med.  Joniiud,  July,  1870. 
RouTH :  "  Fundal  Endometritis,"  London  Obstet.  Transac.,  vol.  xii. 
ScANZoxi:  Disease.'i  of  Femalt's. 
ScHROEUER:  Disease.'t  of  the  Fenude  Sej:ual  Orgaiui. 
SiMP.s(jN,  Sir  James  Y.  :  i>/.sr((.s&s  of  Women. 
Smith,  Tyler:   On  Leiworrhoea. 
Tait,  Lawson:  IJL^ea.ie.i  of  the  Ovarie.s,  1883. 
Tilt  :    Uterine  and  Orarian  Inflanwudion. 

Thomas:   Transac.  Amer.  Gynecolog.  Soc.  vol.  iv.  p.  79  et  seq.,  and  Diseases  of  Women. 
West  :  Dijseases  of  Women. 


Ulcerations  and  Degenerations  of  the  Cervix  Uteri. 

Intimately  connected  with  the  subject  of  chronic  cervical  endometritis 
if<  that  of  ulcerations  and  degenerations  of  the  cervix.  So  much  di.s- 
putation  and  misunder.standing  having  occurred  concerning  the  true 
pathology  of  the  affections  of  the  cervix  called  ulcerations  that  it 
.seems  pr()])er  to  give  a  more  full  and  distinct  mention  of  them. 
Within  recent  years  new  views  of  their  pathogenesis,  based  upon 
micro.scopical  investigation,  have  been  advanced  \\liich  seem  destined 
to  revolutionize  our  previous  ideas. 

XoiiMAL  Anatomy. — The  vaginal  portion  of  the  cervix  is  covered 
with  layers  of  squamous  epithelium  resting  upon  papillte  of  connective 
tissue.  Slender  blood-vessels  ]iass  into  each  and  form  vascidar  loops 
on  their  extremities;  then,  returning,  pass  into  adjoining  pa])illa\ 
According  to  some,  mucous  ciypts  are  found,  though  this  is  denied 
by  De  Sinety.  Ruge  and  Veit  also  consider  their  existence  as  ])nth- 
ological. 

The  cervical  canal  is  lined  with  a  single  layer  of  epithelium,  ciliated 
on  its  free  surface,  folded  so  as  to  form  shallow  reccs.ses.  There  are 
numerous  racemose  mucous  glands  with  branching  ducts.  The  sub- 
stance of  the  cervix  is  made  up  largely  of  connective  ti.s.sue. 


588        THE  INFLAMMATORY  AFFECTIONS  OF  THE    UTERUS. 

Pathological  Anatomy. — The  exact  steps,  according  to  the  old 
and  generally  accepted  view,  in  the  pathological  processes  of  chronic 
cervical  catarrh  by  which,  through  the  influences  of  increased  and 
altered  secretion  of  the  cervical  follicles,  the  infravaginal  mucous  mem- 
brane becomes  macerated,  exfoliates  its  epithelial  layer,  and  proliferates 
its  papillae,  etc.,  have  been  referred  to.  It  becomes  now  our  duty  to 
speak  of  the  results  of  modern  miscroscopical  investigations,  and  to 
show  why  the  recently-advanced  opinions  may  be  accepted. 

Much  of  the  dispute  among  authorities  as  to  whether  these  changes 
are  ulcerative  or  not,  or  whether  "  ulceration  of  the  womb  "  is  a  com- 
mon condition,  is  a  contention  about  non-essentials,  and  arises  from  a 
misunderstanding  among  the  disputants  as  to  what  each  considers 
ulceration.  Dunglison  defines  an  ulcer  as  a  solution  of  continuity 
in  the  soft  parts.  The  exact  extent  and  depth  of  this  solution  of 
continuity  ought  not  to  be  the  points  at  issue.  Is  there  any  solu- 
tion at  all?  A  simple  destruction  of  the  epithelial  layer,  from  what- 
ever cause,  of  whatever  duration,  is  an  ulcerative  process,  superficial 
though  it  be. 

Now,  it  appears  that  the  acceptance  of  the  doctrine  of  any  destruction 
of  tissue  is  based  upon  naked-eye  appearances  during  life  and  micro- 
scopic examination  of  specimens  taken  from  dead  bodies,  in  which  the 
epithelium  has  been  macerated  and  removed. 

Careful  investigations  of  Huge  and  Veit,  who  have  examined  speci- 
mens freshly  cut  from  the  living  subject,  have  demonstrated  that  the 
apparently  raw  surface  seen  through  the  speculum  is  covered  with 
epithelium,  and  that  the  granular  points  supposed  to  be  hypertrophied 
papillae  are  not  connected  therewith,  but  are  new  formations.  The 
appearances,  as  described  by  them,  are  as  follows :  The  seeming  ero- 
sions are  covered  with  cylindrical  cells,  small,  long,  and  narrow, 
having  a  palisade-like  arrangement.  This  layer  of  cells  is  thin,  and 
allows  the  subjacent  vascular  tissue  to  shine  through ;  hence  the  bright- 
red  color.  The  key  to  the  discrepancy  as  to  how  pavement  epithelium 
is  converted  into  cylindrical  is  furnished  by  recognizing  the  fact  that 
acinous  glands  are  found  in  this  portion  of  the  cervix  externally,  and 
especially  internally.  The  glandular  epithelium  proliferates  and  covers 
the  parts  denuded.  The  cylindrical  epithelium  may  detach  the  pave- 
ment epithelium,  crowding  between  it  and  the  underlying  tissue.  An 
enlarged  gland  with  spreading  orifice  displaces  the  pavement  epithelium, 
so  that  an  area  of  protruding  and  proliferating  glandular  lumina  is  seen. 
Thus,  cylindrical  epithelium  seems  to  possess  a  much  greater  energy  of 
growth  than  pavement  epithelium,  displacing  the  latter  and  occupying 
territory  where  not  originally  found. 

Abrasions,  M^osions. — The  raw-looking  surface  called  abrasion  or 
erosion  is  therefore  only  a  newly-formed  glandular  secreting  surface, 


l'lcj:j:atji).\s  am)  j>j:(;hsj:iuTiuss  of  ckiivix  itfui.   ,j.s'.) 

ros('iiil»liiin'  llic  ccrvicMl  imicoiis  lucinhraiic.  licin^  a  practical  additimi 
to  tlic  extent  (•!  "area  ol' scerclioii,  it  necessarily  increases  t  lie  Iciicorrlid'a. 
Tliese  so-called  aliraded  surfaces  arc  Wright  wA,  circular  or  i^-cuci'allv 
in'eiiidar  in  slia|»c.  situated  around  the  cxtcrual  os,  more  rr(M|ncnllv 
the  posterior  eer\ical  li|»,  with  edtics  sonictinics  well  deline(l,  ;uid  often 
hlccdiiio-  easil\-    when    toiielied. 

(i nimihir  / )((/ni<r(ili<)ii. — This  is  really  no  ideci'atioii  at  all.  (ire;it 
proliferation  of  the  cylindrical  e|)itheliiMn  or  of  the  uland.~  causes 
j)r(>tul)erances  to  arise.  The  sui'face  is  furthci'  thi'own  into  mnnerous 
folds,  produciuii-  lilandular  reces.ses  and  processes — j^landular  luniina 
which  have  proliferated  outward.  Such  are  j)aj)illonuitous  ei'osions, 
the  surface  of  which  has  a  ji'nuiular  appearance.  The  condition  pro- 
vokes a  persistency  and  intensity  of  th(^  inor])id  action — hv])er;cniia  and 
increased  secretions. 

These  granulations  are  soft  to  feel,  of  a  vivid  red  color,  show  great 
vascularity,  and  rise  above  the  surrounding  surfaces.  They  sjirout  up 
mostly  around  the  external  os,  but  may  extend  through  the  cervical 
canal.  At  times  they  take  on  great  luxuriance  and  look  like  raspberry 
formations.  Excessive  development  characterizes  the  so-called  "  fun- 
goid ulcer,"  which  when  pressed  upon  and  flattened  down  presents  the 
appearance  of  a  cock's  comb,  called  by  the  English  writers  "  cocks- 
comb granulations."  ^'  Varicose  ulcers  "  are  also  spoken  of.  They  are 
distinct  varicose  venous  plexuses  ramifying  over  the  hypcrtrophied 
])apillre.  Phlyctsense  (Lisfranc),  aphthte  and  herpes  (Lisfranc  and 
Rol)ert),  pemphigus  (Joulin),  are  mentioned.  Thus,  the  great  variety 
of  appearances  in  the  color,  extent,  and  degrees  of  intensity  of  the 
morbid  action  found  in  these  pseudo-ulcerative  lesions  has  temjited 
authors  to  classify  them  like  surgical  ulcers,  but  there  is  no  practical 
sionifieancc  in  such  an  arrany-ement. 

Frequency, — Like  the  disease  from  which  they  ordinarily  proceed, 
these  degenerations  of  the  cervix  are  the  most  frequent  of  the  uterine 
afleetions.  They  attend  a  large  proportion  of  the  cases  of  chronic 
uterine  leucorrhoea,  whether  the  discharge  is  cervical  or  corporeal. 
They  likewise  complicate  parenchymatous  inflammation  of  the  cervix, 
and  are  almost  invariable  concomitants  of  laceration  of  the  cervix. 

Etiology  and  Syjiptoms, — Essentially,  the  same  causes  ]H'oduce 
and  the  same  symptoms  attend  erosions  and  granular  degenei'ations  as 
attend  cervical  endometritis. 

Physical  Signs  and  Diagnosis. — To  the  touch,  the  cervix  feels 
softer,  velvety-like,  or  granular,  having  lost  its  natural  smoothness 
and  flrmness.  Through  the  speculum  the  ])arts  are  .seen  covered  with 
a  thick,  cream-colored  pus,  which  after  removal  gives  an  ajipearance  to 
the  cervix  around  the  os  of  intense  redness  and  vascularity,  the  velv(^tv 
2:ranulations  bcino;  raised  above  the  surroundinu:  surliice. 


590       THE  INFLAMMATORY  AFFECTIONS  OF  THE    UTERUS. 

Such  are  the  signs  in  nulliparae,  and  also  multiparse,  when  the  under- 
structure  of  fibrous  tissue  is  not  diseased  or  lacerated.  If,  however, 
these  conditions  named  should  be  present,  the  cervix  will  be  more  or 
less  enlarged,  thickened,  and  nodulated  from  hyperplasia  and  erosion. 

The  gross  appearances  are  so  characteristic  that  the  diagnosis  is  easy ; 
yet  cervical  laceration  with  ectropion  is  very  liable  to  be  mistaken  for 
granular  degeneration,  so  nearly  do  they  resemble  each  other.  As  on 
a  projaer  diagnosis  the  results  of  treatment  depend,  the  crucial  test  for 
laceration  should  be  made. 

Granular  degeneration  is  easily  confounded  with  cervical  epithelioma 
in  its  earlier  stages. 

Prognosis. — Granular  degeneration  is  one  of  the  most  amenable  of 
uterine  affections. 

Treatment. — The  diagnosis  having  been  clearly  established 
whether  the  degenerate  changes  of  the  cervix  are  primary  or  second- 
ary, the  indications  for  treatment  become  well  defined.  If  the  latter, 
as  the  result  of  uterine  displacement,  a  badly-adjustecl  pessary,  a  per- 
sistent acrid  discharge  from  the  uterine  canal,  a  laceration  with  erosion 
of  the  cervical  lips,  etc.,  these  should  be  first  corrected  before  any  hope 
can  be  indulged  toward  the  accomplishment  of  a  complete  or  permanent 
cure.  The  effects  will  be  repeated  so  long  as  the  cause  remains.  The 
benefits  which  accrue  from  a  replacement  of  the  uterus,  the  adjustment 
of  a  well-fitting  pessary,  the  repair  of  a  laceration,  rest  from  coitus, 
etc.,  are  examples  of  what  can  be  done  by  a  removal  of  the  cause.  While 
the  ulterior  condition  is  receiving  attention  the  granular  degeneration 
itself  must  not  be  neglected.  To  both  cause  and  effect  the  treatment 
is  directed. 

In  all  cases  it  is  of  paramount  importance  that  the  infravaginal  cer- 
vix and  vaginal  canal  be  kept  clean,  free  from  accumulating  secretions. 
The  rules  to  be  observed  in  the  employment  of  vaginal  injections  have 
been  laid  down.  The  medication  of  the  water  with  various  astringents, 
tannic  acid,  zinc  sulphate,  lead  acetate,  with  such  emollients  and  anti- 
septics as  boric  acid,  sodic  biborate,  glycerin,  etc.,  is  highly  advan- 
tageous. 

The  morbid  condition  is  often  most  speedily  brought  to  a  favorable 
termination  in  initiating  the  local  treatment,  not  by  the  use  of  astrin- 
gents and  caustics,  but  by  depletion.  This  is  especially  true  if  the 
srranular  deffcneration  is  marked  and  the  cervix  shows  signs  of  decided 
hvpersemia.  If  the  granulations  extend  throughout  the  cervical  canal, 
several  scarifications  with  a  narrow-bladed  knife  should  be  made  over 
each  wall,  from  just  below  the  os  internum  down  to  the  os  externum 
and  over  such  portions  of  the  infravaginal  face  of  the  cervix  as  are 
implicated.  Congeries  of  superficial  blood-vessels  are  thus  divided, 
the  flow  of  blood  is  free,  and  the  vessels  are  emptied.     Congestion  is 


CYSTK '  /)i:<;/:.\j:i!.i  rios.  r,!i i 

(liiiiiiiislicd.  Puncturing'  luiiy  he  pnictiscd  instciKl  of"  scarilication,  or 
hotli  ni;i\'  lie  utilized  at  the  same  siltinii.  Il'llic  ^•i'anidation>  arc  lar^-c 
and  c\ul)crant  and  lill  up  tlicosand  canal,  tlic\' arc  l)cs(  treated  1»\-  free 
excision  with  the  scissors  and  scra|)in«;-  with  u  sliar|)  cnrctle.  Sncii 
treatment  may  l>('  repeateil  at  ])ro))er  intervals.  When  the  htcai  im- 
|»ro\-ement  is  siitlicicnl ly  advanced,  further  treatment  may  he  Udlowed 
n|)  l)\'  to|)ical  a|)|)lications  at  ])roj)er  intervals  of  emollients,  as  hismnth 
siihnitrate,  l)(»ro-<ilyceride  ;  of  astringents,  as  taiino-j^lycerin,  j^lyceride 
of  alum,  or  Richardson's  styptic  colloid  ;  hy  alteratives,  as  tincture  of 
iodine,  iodoform  ;  and  hy  canstics,  as  nitrate  of  silver  in  solution  or 
I'ravon,  pure  carholic  acid,  nitri(!  acid,  or  chromic  acid. 

Mucous  tissue,  much   hvpei-tro|)liied,  [)roti'iidinL!,'  and  everted,  is  best 
treated  hv  thorouirh  excision. 


Cystic  Degeneration. 

This  is  a  degenerate  change  of  the  mucous  follicles  of  the  cervical 
canal  and  the  infravaginal  face  of  the  cervix.  Granting  that  there  are 
no  racemose  glands  on  the  vaginal  portion  beyond  the  limits  of  the  os 
externum,  the  degenerate  follicles  there  found  in  this  disease  must  be 
produced  from  the  mucous  membrane  of  the  cervical  canal  or  from  the 
newly-formed  glandular  tissue. 

Pathology. — The  changes  are  variable,  and  indicate  degrees  of  the 
pathological  processes.  First,  there  are  a  number  of  vesicles,  in  size 
from  a  millet-seed  to  a  pea,  filled  with  a  thick  gelatinous  fluid  due  to 
re[)letion  from  retention.  The  secretion  becomes  inspissated.  The 
efferent  duct  of  the  gland  becomes  compressed  by  the  swollen  peri- 
glandular tissue,  as  well  as  by  the  neighboring  glands.  A  retention- 
cyst  is  formed  called  "  ovulum  Nabothi."  The  development  of  these 
retention-cysts  is  hindered  by  the  great  resistance  of  the  tissues ;  hence 
their  formation  is  most  readily  effected  at  the  surface.  Second,  the 
cysts  have  opened,  either  spontaneously  by  internal  pressure  or  l>y 
trauma;  the  cylindrical  epithelium  is  laid  bare — follicular  erosion;  or 
their  contents   may  undergo  suppuration  and  form  mimite  abscesses. 

If  the  tissues  are  very  firm  the  cysts  elevate  themselves  from  the 
parenchyma.  Hanging  from  the  os,  they  assume  the  shajie  of  small 
poh'pi.  They  may  gradually  acquire  a  long  stem,  and  several  sec- 
tions of  the  gland  may  proliferate. 

Thus,  cystic  degeneration  is  glandular  hypertrophy,  and  the  forma- 
tion of  ncAV  glands  is  resultant  on  the  epithelial  proliferation  ])reviously 
described.  The  growth  of  the  glands,  whether  from  the  internal  sur- 
faces of  the  cervix  or  from  underneath  the  squamous  epithelium,  is 
sometimes  enormous.  So  great  may  be  the  glandular  hyperphisia 
involved   that   the  entire  vaginal  cervix   mav  be  converted  into  one 


592       THE  INFLAMMATORY  AFFECTIONS  OF  THE    UTERUS. 

cystic  mass,  a  cavernous  tumor,  the  connective  tissue  having  been 
eifaced.  A  section  of  the  cervix,  as  in  amputation,  may  thus  cut 
through  innumerable  retention-cysts  filled  with  mucus.  The  whole 
exterior  surface  secretes  large  quantities  of  mucus. 

Fritsch  describes  this  enormous  hypertrophy  which  takes  place  in 
the  glands  of  the  cervix,  so  that  the  part  becomes  almost  an  adeno- 
matous structure.  A  persistency  of  this  condition  after  the  puer- 
perium  partly  explains  the  frequency  of  chronic  cervical  catarrh  in 
multiparae. 

Etiology. — The  causes  of  cystic  degeneration  are  chronic  conges- 
tion and  hyperplasia  of  the  cervix,  chronic  cervical  endometritis,  and 
especially  lacerations. 

Diagnosis. — Touch  may  be  sufficient  to  detect  the  enlarged  follicles 
on  the  exterior  of  the  cervix  or  within  the  cervical  canal.  The  spec- 
ulum M'ill  confirm  the  diagnosis. 

All  of  the  above-mentioned  pathological  changes  may  be  revealed  in 
a  single  case. 

The  PROGNOSIS  is  favorable. 

Treatment. — The  first  step  consists  in  thoroughly  emptying  the 
distended  glands.  This  is  best  done  by  freely  puncturing  each  cyst 
with  Buttle's  scarificator  or  a  knife  with  small-pointed  blade.  It  is 
useless  to  attempt  to  search  for  each  individual  cyst,  for  the  whole 
degenerated  or  Vcerated  surface  may  be  jiassed  over  by  numerous  little 
stabs  in  all  di^  etions  at  each  sitting,  and  the  process  repeated  from 
once  to  twice  each  week  until  a  radical  improvement  is  effected.  The 
local  bleeding  is  rarely  free,  and  in  itself  is  beneficial.  Not  only  Avill 
the  cervix  now  present  an  improved  color,  but  be  reduced  in  size,  and 
the  everted  flaps  from  laceration  assume  a  better  shape. 

Cauterization  of  each  cyst-cavity  with  nitrate  of  silver  or  pure  nitric 
acid  is  rarely  necessary,  but  may  be  reserved  for  the  more  rebellious 
cases. 

Applications  of  tanno-glycerin  and  strong  tincture  of  iodine,  as 
described  under  the  subject  of  Chronic  Cervical  Endometritis,  are 
very  useful. 

Failing  to  arrest  the  degeneration  by  these  means,  an  eifort  should 
be  made  to  extirpate  the  glands  of  the  cervical  canal  by  thorough 
scraping  with  a  sharp  steel  curette,  followed  by  free  cauterization  with 
the  hot  iron ;  or,  as  a  last  resort,  the  infravaginal  cervix  may  be  ampu- 
tated by  scissors  or  the  galvano-caustic  wire. 

The  importance  of  a  thorough  eradication  of  the  cystic  degeneration 
of  the  cervix  following  laceration  before  tracheloplasty  is  undertaken 
cannot  be  over-estimated,  since  its  continuance  is  very  apt  to  endanger 
an  otherwise  successful  result  of  this  operation. 


TRUE  ULCKiiATinys  OF  Till-:  ci'.nvix  i'T/:/:f.  ',u:i 

True  Ulcerations  of  the  Cervix  Uteri. 
A    true   iilccrativi'   process,  with   (Icstnictiini   of   the  cpitlicliiiiii   jiiid 
iiii(l('rl\iti!i'   tissues,  docs  sometimes,  tlioiiH-li   rarely,  occur.     (XCoiirsj* 
rofei'euce  is  not   li;t<l  to  uN'eratioiis  coiisecjiieiit  on  mali^;iiaiit  dixax — a 
condition  very  common. 

SYPHILITIC   ULCERATIONS. 

Tf  there  is  any  point  in  ntci-ine  patliolot;y  well  settled,  it  is  that 
syphilitic  uU-erations  are  e.\eci'dini!;ly  rare  in  this  rej^ion.  Not  (jnly  is 
this  true  iJS  to  the  primary  sore — ciiancrc  or  chaneidiil — but  set^ondary 
formations,  as  niucous  patches,  acknowledged  to  Ite  tiie  nio.st  frequent 
of  all  the  manitestations  of  this  stage  of  this  disease,  are  very  infre- 
quent. The  testimony  of  most  observers  agrees  as  to  these  points,  and 
ill  substantiation  such  authorities  as  Rieord,  Cullerier,  Duparcque,  and 
liumstcad  may  be  cited.  But  .some  .statistics  offered  by  Fournier  would 
indicate  their  greater  frequency. 

When  present,  true  syphilitic  ulcerations  may  be  recognized  by  the 
usual  evidences  of  a  well-defined  border,  which  is  indurated,  surround- 
ing a  depressed  area,  manifesting  a  great  tendency  to  be  covered  with 
false  membranes,  as  has  been  observed  by  Robert  and  Bernutz.  Ac- 
cording to  Rieord,  they  are  found  more  often  on  the  anterior  than  the 
po.sterior  cervical  lip.  Commencing  as  a  simple  erosion,  they  quickly 
become  deep  ulcers,  and,  according  to  Forster,  may  perforate  the  blad- 
der and  the  rectum.     Constitutional  .symptoms  rapidly  develop. 

The  DIAGNOSIS  rests  upon  the  appearance  of  the  ulcer,  its  rapid 
progress  in  one  previously  free  from  local  trouble,  the  quick  develop- 
ment of  constitutional  symptoms,  and  its  inoculability. 

Secondary  eruptions,  as  mucous  patches  and  vegetations,  are  recog- 
nized by  their  rapid  local  development,  associated  with  characteristic 
constitutional  .signs. 

What,  now,  is  the  nature  of  the  abrasions  and  granular  degenerations 
so  frequently  found  in  ])atients  suffering  wnth  constitutional  syphilis? 
They  are  the  same  in  kind  and  degree  detected  in  women  who  have  no 
syphilis.  They  arise  from  common  causes,  local  and  general — sexual 
abuses,  dissipation,  habits  of  uncleanliness,  and  impaired  general  health. 
Treatment. — Xon-specific  ulcerations  may  be  treated  like  pseudo- 
ulceration.     Specific  ulceration  requires  antisyphilitic  medication. 

Bihl'tography. 
Barxks:  Diseascit  of  Women,  1878. 
BuMSTEAD :    Venereal  Diseases. 

De  Sinety:  Practical  Manual  of  Gynecologij,  Paris,  1879. 
Fritsch:  Di.'<eases  of  Women,  1883. 
Hart  and  Barbour  :  Manual  nf  Gyncrrolocm,  1886. 
RuGE  and  Veit:  Pathohgy  nf  Vaf/inol  Cervix. 
Thomas:  Diseases  of  Women,  IS80. 
Vol.  I.— 38 


594       THE  INFLAMMATORY  AFFECTIONS  OF  THE   VTERUS. 

Uterine  Fungositibs. 

Intimately  associated  with,  and  dependent  upon,  some  of  the  varieties 
of  chronic  endometritis  of  the  corporeal  cavity  are  fungosities  or  a 
fungoid  degeneration  of  the  endometrium.  It  is  a  disease  of  great 
frequency,  and  its  recognition  aifords  a  key  to  not  a  few  cases  of  men- 
orrhagia,  metrorrhagia,  and  leucorrhoea.  Fungosities  proper  are  not 
found  in  the  cervical  canal. 

Pathology. — The  conditions  found  are  variable.  At  times  (a) 
there  is  a  thickened,  pulp-like  state  of  the  mucous  membrane — a  uni- 
form general  hyperplasia  of  the  whole  surface,  without  any  projections. 
Again,  (6)  there  are  found- sessile  vegetations,  in  size  from  a  millet-seed 
to  a  pea,  studding  the  mucous  surface  in  patches  or  spread  over  the 
whole  area.  They  are  red,  gelatinous-like,  and  eroded  by  chronic 
catarrh,  and  have  an  abundance  of  vascular  supply.  And  (c)  there 
are  numerous  projections  of  fungoid  material,  polypoid-like,  scattered 
over  a  hyperplastic  mucous  membrane. 

Olshausen  termed  this  disease  endometritis  hyperplastica  chronica,  seu 
polyposa.  Microscopically,  he  describes  these  fungosities  as  hyper- 
trophied  mucous  membrane,  with  an  increase  of  all  its  histological 
elements — dilated  follicles,  enlarged  blood-vessels,  and  great  cell-pro- 
liferation. Slavjansky  has  styled  the  disease  metritis  interna  villosa. 
All  these  three  neoplastic  formations  may  be  combined. 

Placental  villosities  are  very  frequently  detected  in  the  uterus,  espe- 
cially after  abortions  at  the  second  to  the  third  month ;  more  rarely 
after  term.  The  symptoms  of  their  presence  are  the  same  as  from 
uterine  fungosities,  and  it  is  difficult  to  difPerentiate  between  them. 
Retention  of  adherent  placental  villi  is  a  common  source  of  endo- 
metritis hyperplastica. 

Finally,  diffuse  or  soft  sarcoma  of  the  corporeal  mucosa,  and  adenoma, 
a  glandular  disease,  may  be  present.  Both  are  rare  affections,  and  both, 
especially  the  former,  manifest,  even  when  seemingly  wholly  removed, 
a  strong  tendency  to  return.  The  diffuse  sarcoma  shows  soft,  flabby, 
villous  groAvths,  assuming  an  irregular  polypoid  shape,  spreading  over 
the  whole  surface,  rapidly  proliferating. 

Etiology. — Chronic  endometritis  is  unquestionably  the  most  com- 
mon cause.  Associated  with  endometritis,  there  may  be  a  subinvolution 
of  the  uterus.  Displacements  and  flexions,  either  as  the  result  or  cause 
of  chronic  hypersemia,  are  etiological  factors. 

These  fungosities  are  noticeably  frequent  in  marked  retroflexion 
and  retroversion.  Intra-uterine  and  interstitial  fibroids,  which  enlarge 
the  uterus  and  augment  its  blood-supply,  lead  to  similar  changes  in 
the  mucous  membrane. 

A  neglected  laceration  of  the  cervix,  if  sufficient  to  produce  gaping 
of  the  cervical  walls  and  eversion,  is  almost  invariably  thus  complicated. 


UTEIUSK  FVMJOSITIKS.  r>!)5 

Eiirorccd  st<'rilitv,  impls  ill";-  ;i  disrc^^arcl  (»t' Xat lire's  laws,  (Iciniiiidiiij^ 
stati'tl  pcriiHls  of  rest  wliicli  alone  pregiiaiiey  and  laetatioii  <'aii  hciii;.'-,  is 
a  eaii>e.  In  tine,  pioloiiLicd  uterine  congestion,  iVoiu  whatever  eaii.~e  or 
condition,  is  tlie  chief"  imderlyiiiii;  causative  iiiHiienee. 

SvMP'roMATo Loci's'. —  I'lie  most  si^nilicant  syinptoin  is  utei-ine  heni- 
ori'ha^e,  which  hohls  no  |)ro|)ortioii  either  to  the  number  or  si/e  ol"  the 
riinu'osities.  The  menstrual  How  may  he  i^reatly  increased,  prolonged, 
or  a|)|>ear  with  increasing-  rre(jueii<y.  Metrorrha<;ia  or  non-menstrual 
uterine  liemorrha<i,-e  may  supplement  the  menstrual  How  i»roj)er,  the 
hemorrhaiie  thus  hecoiniui;-  contimial.  More  or  less  tiin<;-oid  material 
mav  he  cast  oil'  S[)outaneously,  mixed  with  hlood.  In  the  ahseiice  of 
hemorrha<!;e  there  is  generally  more  or  less  mucous  or  muco-purulent 
leiicorrlKca.  The  remaining  symptoms  are  such  as  are  present  in  (jrdi- 
iiarv  endometritis.  Sterility  is  the  rule.  As  a  consequence  of  the  local 
drain  the  general  health  becomes  greatly  depreciated  and  anaemia  may 
be  profound. 

While  uterine  fungosities  are  a  condition  particularly  of  the  child- 
bearing  years,  it  is  occasionally  perpetuated  long  after  the  climacteric. 

Diagnosis. — The  rational  symptoms  create  a  strong  suspicion  of  the 
nature  of  the  disease.  The  uterus  is  somewhat  enlarged,  tender,  and 
the  canal  patulous,  and  there  is  catarrh.  The  entrance  of  the  index 
linger  through  the  dilated  canal  may  enable  one  to  feel  the  soft,  spongy 
endometrium. 

A  confirmation  of  the  diagnosis  is  reached  by  a  physical  exploration 
of  the  uterine  cavity  made  with  the  wire-looped  curette  gently  passed 
down  over  the  walls  and  within  the  angles  of  the  horns  of  the  uterus. 
To  the  touch  a  roughened  sensation  is  communicated  as  the  curette 
glides  over  the  diseased  surfaces.  Portions  of  the  diseased  membrane 
or  placental  villosities,  as  the  case  may  be,  will  be  removed.  This  is 
the  only  sure  test  of  the  existence  of  these  fungosities.  A  gentle  scrap- 
ing will  dislodge  them  if  present ;  if  there  are  none,  no  harm  is  done. 

To  the  experienced  eye  the  appearance  of  the  morbid  material 
removed  is  sufficient.  Either  it  will  be  surfaces  of  thickened,  soft- 
ened, hyperplastic  mucosa,  patches  of  low  soft  granulations,  polypoid 
formations,  placental  villosities,  if  benign,  or  villous  growths  if  sar- 
comatous ;  glandular  formations  if  adenomatous.  Any  doubt  as  to  tlie 
exact  nature  of  each  may  be  solved  by  a  careful  microscopical  exami- 
nation, the  histological  features  being  characteristic. 

The  quantity  removed  may  be  very  slight,  up  to  one  and  several  tea- 
spoonfuls.  The  regions  of  the  uterine  cornua  seem  to  ho  flivorite  seats 
for  their  localization  ;  also,  the  site  of  the  placental  attachment  in  those 
cases  which  have  followed  abortions  and  parturitions  at  term. 

Prognosis. — Tliis  is  almost  always  favoral)le,  provided  a  correct 
diagnosis  is  made  and  a  proper  course  of  treatment  is  instituted.     The 


596       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

prognosis  is  certainly  favorable  if  the  diagnosis  settles  the  benignity  of 
the  fungosities ;  equally  unfavorable  if  they  should  prove  to  be  sar- 
comatous. 

It  is  always  well  to  bear  in  mind  that  the  disease  is  liable  to  return, 
and  treatment  may  have  to  be  repeated  from  time  to  time  in  a  certain 
proportion  of  cases,  especially  when  the  uterine  engorgement  from  any 
cause  cannot  be  effectually  controlled.  Where  resultant  on  flexion  or  a 
constricted  cervical  canal  permanent  relief  cannot  be  expected  until  the 
original  aifection  is  remedied. 

Treatment. — The  one  essential  feature  of  the  treatment  of  uterine 
fnngosities  is  their  radical  removal.  Constitutional  treatment,  except 
for  the  purpose  of  improving  the  general  health,  is  of  no  avail,  and 
intra-uterine  cauterization  is  uncertain  and  unsatisfactory.  The 
stronger  caustics  may  destroy  these  granulations,  but,  aside  from  the 
danger  arising  from  repeated  cauterizations,  and  this  tendency  to  the 
formation  of  hard,  cicatricial  mucous  membrane,  the  curette  treatment 
is  less  painful,  more  rapid,  more  safe,  convenient,  and  eifectual. 

Use  of  the  Curette:  Indications,  Contraindications. — R^camier  of 
Paris  in  1846  had  the  honor  to  introduce  the  curette,  which  original 
instrument  (Fig.  193)  has  largely  gone  into  disuse.     For  a  long  time 

Fig.  193. 


K^camier's  Curette. 


its  use  met  with  much  opposition,  having  been  pronounced  unscien*- 
tific  and  barbarous  by  such  men  as  Chassagnac,  Scanzoni,  and  others. 
AVithin  recent  years  the  instrument  has  been  greatly  modified  and  its 
use  rendered  perfectly  safe.  Those  at  hand  are  the  dull  wire  curette 
of  Thomas  (Fig.  194) ;  the  sharp  steel  curette  of  Sims  (Fig.  195),  with 


^ 


Fig.  194. 


Thomas's  Curette. 


flexible  handle;  the  sharp  cutting  spoon-curette  of  Simon  (Fig.  196)^ 
with  a  stiff  shank;   and  the  curette  forceps  of  Emmet  (Fig.  197). 

Thomas's  instrument  of  copper  wire,  without  cutting  edge,  is  now  in 
general  use,  and  quite  justly  so,  answering  as  it  does  not  only  for  the 
purpose  of  a  thorough  diagnosis,  but  in  the  great  majority  of  cases 
being  all-sufficient  to  safely  and  effectually  dislodge  the  fungosities. 
Sims's  sharp  curette  should  be  reserved  for  the  destruction  of  hyper- 


UTER ISK  FL'SU  US  1 1  'IKS. 


\)7 


trophit'd  «;l;m(ls  ol'  the  cervical  canal  and  those  rait-  instances  of  dis- 
eased n|)|)er  c-nd(tnieti'inni  wiiere,  after  repeated  I'ailm-e  willi  the  didl 
wiiH-  instrunienl,  a  nmi'e  jxiwiTlni  inipressinn  ami  tlioronLili  renioxa!  nt" 
liNiHTtnipliied    nuici).-a   are   necessary.      ^Sevi-r  shonld    it    i)e  .selected  to 


Imu.  195. 


Sims's  Sliari>  Curette  :  a,  h,  showinj;  the  angles  iit  wliich  it  may  l>e  bent. 

initiate  cnrette  treatment  unless  it  be  for  the  removal  of  sarcomatou.s 
growths.  Emmet  is  very  severe  in  his  denunciation  of  Sims's  in.stru- 
ment,  stating  that  "the  ingenuity  of  man  has  never  devised  one  capa- 
ble   of  doing    more    harm " — an    expression    doubtless    true    if  it   is 

Fig.  196. 


J.T/EM/iMJ  &C0 

Simon's  Spoon. 


employed  by  unskilful  hands  or  as  frequently  as  is  the  dull  wire 
curette.  But  the  sharp  curette  is  by  no  means  to  be  laid  aside  and 
abandoned.     It  has  its  place  and  power. 

Emmet's  curette  forceps,  introduced  as  a  substitute  for  Sims's  curette, 


Fig. 197. 


Emmet's  Curette  Forceps. 

removes  only  such  granulations  as  project  above  the  common  level  of 
the  surrounding   membrane. 

Simon's  spoon-curette  was  designed  (1872)  for  the  removal  of  malig- 
nant growths.  Motlifications  of  it  with  serrated  edges  possess  special 
advantages. 

Any  one  of  these  curettes  can  be  employed  without  the  speculum, 


598       THE  INFLAMMATORY  AFFECTIONS   OF  THE    UTERUS. 

but  the  proper  application  is  best  obtained  by  the  use  of  Sims's  spec- 
ukim  in  the  left  lateral  semi-prone  (or  Simon's)  position,  the  uterus 
being  steadied  Avith  a  tenaculum.  Artificial  dilatation  is  seldom  re- 
quired. The  curette  is  made  to  systematically  scrape  all  the  uterine 
walls  from  fundus  to  os  internum,  not  neglecting  the  regions  of  the 
metro-salpingian  orifices.  Its  withdrawal  is  followed  by  the  fungoid 
villous  accumulations  or  the  hyperplastic  mucous  tissue,  and  more  or 
less  flow  of  blood.  Rarely  is  the  latter  profuse,  and  it  generally 
quickly  ceases.  This  loss  of  blood  is  not  only  protective,  but  is 
directly  beneficial  in  depleting  from  the  congested  endometrium. 
Varicose  vessels  ramifying  upon  the  surface  are  thus  broken  up, 
and  many  others  are  emptied. 

The  vagina  may  now  be  irrigated  with  a  stream  of  hot  water,  and, 
if  necessary,  intra-uterine  medication  with  iodine  tincture,  carbolic 
acid,  iodized  phenol,  or  nitric  acid  may  be  inaugurated — always  if 
the  growths  are  found  to  be  malignant.  Comparatively  slight  pain 
usually  attends  this  minor  operation,  an  anaesthetic  seldom  being  re- 
quired. The  dangers  also  are  slight.  Rarely  does  an  attack  of  pelvic 
peritonitis  or  cellulitis  supervene.  But  the  risks  of  curetting  are  con- 
siderably increased  if  made  to  immediately  follow  tenting.  Antiseptic 
precautions  should  always  be  observed.  As  a  matter  of  ordinary  cau- 
tion it  is  prudent  that  this  operation  be  performed  at  the  patient's  resi- 
dence, and  that  she  remain  in  bed  for  several  days  thereafter — longer 
if  any  unpleasant  symptoms  develop. 

The  effects  of  curetting  are  usually  very  prompt  and  decided  in  con- 
trolling uterine  hemorrhage  arising  from  causes  here  before  described. 
Quite  excellent  effects  also  are  produced  on  the  congested  mucous  mem- 
brane even  when  no  fungosities  are  found.  The  forthcoming  period  is 
at  times  considerably  delayed;  more  often  its  first  appearing  at  the 
ordinary  time  is  profuse,  while  subsequent  ones  become  normal  in 
quantity.  Repetition  of  the  curetting  may  be  necessitated  from  time 
to  time  on  account  of  relapses  of  the  symptoms  from  re-forming  of  the 
vegetations.  Thorough  removal  of  old,  diseased  mucosa  favors  the 
regeneration  of  a  new,  better  structure. 

In  these  more  stubborn  cases  the  best  results  may  be  secured  by 
follo-^dna;  each  curetting  with  one  to  two  intra-uterine  treatments  of 
iodine,  iodized  phenol,  or  nitric  acid.  The  use  of  the  curette  may 
quite  often  not  only  initiate,  but  entirely  supplant,  intra-uterine  medi- 
cation. 

So  great  are  the  benefits  to  be  derived  from  the  proper  use  of  the 
curette  in  judiciously  selected  cases  of  chronic  corporeal  disease  that  its 
introduction  is  certainly  one  of  the  greatest  advances  in  the  manage- 
ment of  many  conditions  heretofore  almost  unmanageable.  The  con- 
traindications to  its  use  are  the  same  as  for  intra-uterine  medication. 


ciiJiusic  MKTiwns,  ETC.  OF  I'll  I :  rri-jii's.  r>i)y 

JiUtlioyraphy. 
Couuty:  Malttd.  de  r  Ulrni.-<,  18S3. 
K.MMET:   Principles  and  I'raiiirr  oj   Gi/mroloffi/^  p.  CA7. 
GuDDKLL :    //(wcd.s  in  (fi/mroloifif,  1.S80. 
IIaut  ani>  IJAiMJoru:   Mnunal  nf  ( hjuctcology,  1883. 
MlNUli:   Minor  iSui(/irid  (ii/necoliMji/,  l8So, 
Thomas:  Diaeases  oj'  Women. 


Chronic  Metritis,  Subinvolution,  Hyperjemia,  Hypertrophy, 
Hyperplasia,  Sclerosis,  Atrophy  of  the  Uterus. 

Definitions,  Synonyms,  and  NoMENCLATrni:. — Tlic  term  chroiiif' 
metritis  is  used  to  ('.\])r(ss  a  morbid  ])roc('ss,  formei'ly  iiiiivcr.^allv  .•sup- 
posed to  bo  iiiHammutory,  involving  the  Hl)rous  strnc-tnro  ot"  the  nterus. 
The  term  is  retained,  in  the  absence  of  a  better  one,  to  express  its  eor- 
reet  pathoh)uv.  While  it  is  not  regarded  by  most  authorities  a.s  a  true 
inHammation,  it  possesses  many  features  like  it.  The  various  names 
or  sxiionvms  bv  whieh  this  ati'eetion  is  known  are — ehronie  con<»;estion, 
hypenemia ;  chronic  infarctus  (Kiwisch) ;  engorgement  (Lisfranc) ; 
chronic  parenchymatous  inflammation  of  the  womb  (Scanzoni) ;  diffuse 
growth  of  the  connective  tissue  (Klob)  ;  subinvolution;  hvpertroj)hv  ; 
areolar  h^-perplasia  (Thomas) ;  irritable  uterus  (Hodge) ;  diffuse  inter- 
stitial metritis  (Xoeggerath) ;  sclerosis  ;  atrophy.  Some  of  these  terms 
are  inaj)plicable,  convey  most  imperfect  ideas  of  the  nature  of  the 
pathology,  and  exjjress  merely  certain  symptoms  or  a  single  feature 
of  the  disease.  Strictly  speaking,  chronic  meti'itis,  as  now  understood, 
is  a  complex  morl)id  process  embracing  diilcrent  stages  and  varied  con- 
ditions.    It  is  the  most  important  disease  of  the  female  sexual  organs. 

Pathologicai>  Anatomy. — Until  within  recent  years  it  has  been 
supjioscd  that  the  so-called  chronic  metritis  was  but  the  chronic  stage 
of  the  acute  inflammation  of  the  fibrous  tissue  of  the  uterus.  The 
error  of  such  a  view  is  now  a]>]>arent  when  we  consider  the  great  raritv 
of  acute  parenchymatous  metritis,  as  shown  by  all  auto})sic  examina- 
tions, and  the  clinical  fact  that  most  cases  of  chronic  metritis  have  never 
manifested  any  acute  symptoms.  To  recent  investigations,  chiefly  micro- 
scopic, in  pathology  are  we  indebted  for  a  correct  understanding  of  the 
morbid  processes  in  this  disease. 

That  chronic  metritis  can  be  engrafted  u])on  acute  parcnchvmatous 
metritis  occurring  in  the  puerperal  bed  is  admitted.  A  uterus  enlarged, 
its  muscular  walls  thickened,  soft,  ])ul])y,  the  cut  surfoce  of  which  would 
show  a  bright-red  color  with  engorged  veins,  the  interstices  yielding 
on  conijircssion  a  red  exudation,  and  the  muscular  fibres  infiltrated  Mith 
])us-corpuscles,  presents  a  condition  which  may  become  chronic  or  lead 
to  the  pathological  changes  detected  in  chronic  ]iarenchymatous  metritis. 
As  stated,  very   few  cases  atlbrd  any  such  antecedent  history.     Most 


coo       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

are  ushered  in  so  slowly  and  insidiously  that  it  is  difficult  to  determine 
the  date  of  inception. 

It  is  to  the  condition  of  the  uterus  after  parturition  at  term  or  after 
an  abortion  that  we  are  to  look  for  an  explanation  of  the  processes 
which  lead  to  many  of  these  cases  of  chronic  parenchymatous  disease. 
The  puerperal  uterus  is  large,  heavy,  flabby,  and  usually  anteverted. 
The  whole  organ  during  gestation  has  undergone  an  enormous  hyper- 
trophy, its  muscular  fibres  having  assumed  colossal  proportions.  It 
weighs  after  delivery  from  twenty-two  to  twenty-four  ounces  (Heschl), 
and  measures  in  length  from  twelve  to  nineteen  centimeters  (four  and 
three-quarters  to  seven  and  a  half  inches)  (Boerner).  The  interior  of 
the  organ  is  bathed  with  a  disintegrating  fluid,  and  the  placental  site 
shows  large  venous  sinuses  plugged  with  newly-formed  thrombi.  The 
whole  interior  mucous  membrane  is  not  cast  oflP,  as  was  formerly  sup- 
posed, but  a  separation  in  the  deciclua  itself  takes  place,  regeneration 
commencing  from  the  remaining  portion.  The  new  membrane  is 
usually  formed  during  the  third  and  fourth  weeks. 

The  revolution  by  which  this  immensely  hypertrophied  organ  is 
reduced  to  almost  its  original  size  and  weight  before  pregnancy  is 
called  involution.  It  is  accomplished  partly  through  the  drainage  of 
the  lochial  discharges,  but  largely  through  the  action  of  fatty  degene- 
ration. The  muscular  fibres  undergo  a  fatty  metamorphosis,  in  conse- 
quence of  which  they  melt  down  and  disappear,  being  absorbed  as  fat. 
This  fatty  metamorphosis  is  easily  discernible  under  the  microscope  in 
each  individual  fibre  a  few  days  after  delivery,  commencing  in  those 
near  the  mucous  surface  and  extending  outwardly.  In  a  fortnight  after 
parturition  the  uterine  length  is  reduced  to  some  nine  to  twelve  centi- 
meters (three  and  a  half  to  four  and  a  half  inches),  and  the  weight  to 
ten  or  eleven  ounces.  The  observations  of  Boerner,  Heschl,  and  Sin- 
clair go  to  show  that  the  loss  in  weight  and  the  diminution  in  size  are 
comparatively  little  at  the  end  of  the  first  week,  but  greatest  during  the 
second  week,  and  that  at  the  end  of  the  third  the  uterus  is  still  three 
to  four  times  heavier  than  the  non-puerperal  organ  (one  ounce  and  a 
half).  This  whole  transformation — one  of  absorption  and  regeneration 
— is  ordinarily  not  completely  accomplished  short  of  the  end  of  the 
second  month.  It  varies  much  in  different  subjects,  both  in  the  rapidity 
and  degree  of  its  action,  being  influenced  greatly  by  conditions  local 
and  general.  It  is  more  rapid  and  perfect  in  the  primiparee  than  the 
multiparse.  It  is  also  delayed  and  made  incomplete  by  a  poor  state  of 
the  general  health,  inherited  or  acquired.  Failure  of  suckling  one's 
own  infant  is  a  hinderance  to  its  accomplishment.  The  local  conditions 
impeding  involution  are  traumatic  lesions  of  the  cervix,  retention  of 
portions  of  placenta,  membranes,  blood-clot,  septic  absorption,  the  super- 
vention of  endometritis,  uterine  phlebitis,  pelvic  cellulitis,  etc. 


t^\ri{f-        ..1 


Fi§2 


I''i''  .   1  .    riiioiiii-     I  I\-|i<  ■li.fjrn  i  n  ,  f  ■  Ji  t  iii-fK  ,  n  r  \  (1    !•',  1 1 1  iar>^  em  <■  i  1 1 

P'iL;.!'.    CliroMic     Mi-liitiw     i\ncl    F]  j  u  1  fiin  e  li- i  t  i  s     (Mei^s). 

To  face  pafao  001. 


CllROMC  METlllTlS,   KTC.    OF   THE    ITLliL'^.  (JUl 

Arri'stiHl  rctrot^nulc  involution  is  calKMl  ftiihlnvo/iition. 
I'rct-isfly  tlu'  siuiu-  process  in  kind,  (liU'crinj;  only  in  (iegrcc,  occurs  in 
tlic  uterus  followint:;  each  menstrual  perifnl.     There  i.s  then  menstrual 
inv(»luti(»n,  and  there  may  he,  in  eonsefjiienee  of  imj)e<led  circulation, 
mvitf!lru(t/  suhinroliifioii. 

Now,  puerperal  .subinvolution  of  the  uterus  is  the  ciiief  underlying 
condition  or  factor  in  the  pnKluction  of  the  so-callc<l  chronic  metritis. 
Anythiiiir  \vhich  interferes  with  normal  involution  predispos<'s  to  chronic 
metritis.  The  prominent  feature  of  subinvolution  is  increascfl  va.scu- 
larity — ln/jjrrtnnia.  The  condition  is  a  chronic  one,  and  may  have  an 
indefinite  continuance.  But  its  protraction  for  a  Ictnj;  peritxl  of  time 
is  followed  sooner  or  later  by  certain  changes  in  the  ti.ssues  of  the 
parenchyma.  At  the  beginning  hypertrophy  of  the  muscular  struc- 
ture, eijually  with  the  connective  tissue,  is  found.  As  time  advance.-^ — 
it  may  be  a  few  months  or  even  yeans — microscopic  section  will  show  a 
great  preponderance  of  the  connective  tissue.  As  a  result  of  the  ])er- 
sistent,  habitual  liyperffiniia  this  tissue  takes  on  this  increased  growth 
or  proliferation.  The  same  proliferation  may  follow  in  the  muscular 
structure,  but  it  is  always  there  limited,  and  usually  absent.  The  mus- 
cular structure  is  therefore  relatively  diminished,  and  it  may  be  abso- 
lutely, by  the  connective  tissue  supplanting  it. 

At  first,  then,  the  uterus  is  enlarged,  heavy,  flabliy,  soft,  and  hvper- 
jemic.  Later  on,  as  a  preponderance  of  the  connective  tissue  results 
through  its  proliferation,  the  organ  is  found  dense  and  indurated  ;  at 
the  same  time  it  becomes  less  vascular.  Diminished  vascularitv  is 
brought  about  by  the  groA\'th  of  the  intermediate  az'eolar  tissue  espe- 
cially surrounding  the  blood-vessels,  compressing  them  and  cutting  off 
the  current  of  their  supply.  This,  the  second  stage  of  the  disease,  is 
called  hyperplasia. 

Still  later  on  a  further  change  becomes  manifest,  the  result  of  the 
former.  Advancing  proliferation  and  hyperplasia  of  the  connective 
tissue  renders  the  parenchyma  of  the  uterus  more  and  more  dense  and 
indurated,  less  and  less  vascular,  until  finally  a  condition  is  found  as 
descriijed  by  Klob.  The  parenchyma  on  section  appears  white  or 
whitish-red,  deficient  in  blood-vessels,  and  its  firmness  is  so  increased 
by  contraction  and  condensation  that  it  creaks  under  the  knife,  simu- 
lating the  hardness  of  cartilage.  The  uterus  now  g-rows  smaller  and 
undergoes  atrophy.     This  is  the  stage  of  sclerosis  or  cirrhosis. 

We,  then,  may  recognize  three  distinct  stages  of  chronic  parenchyma- 
tous metritis:  1,  hypenemia  ;  2,  hyperplasia;  3,  sclerosis.  The  second 
is  a  result  of  the  first,  and  the  third  is  a  practical  continuance  of  the 
second.      (Plate  III.) 

From  a  pathological  point  of  \new  the  term  "  chronic  metritis  "  has 
been  deemed  incorrect,  inasmuch  as  it  implies  an  acute  stage  of  an 


602       THE  INFLAMMATORY  AFFECTIONS   OF  THE  UTERUS. 

inflammation  which  rarely  exists,  and  since  a  study  of  the  morbid 
anatomy  has  failed  to  demonstrate  the  evidences  of  a  chronic  inflamma- 
tion. But,  as  Hart  and  Barbour  state,  the  term  is  very  convenient 
from  a  clinical  standpoint,  because  we  possess  none  better  to  embrace  a 
variety  of  conditions  presenting  the  same  clinical  features  on  examina- 
tion. Very  recently,  Dr.  Mary  P.  Jacobi  has  presented  an  elaborate 
and  strong  argument  in  favor  of  the  older  view,  that  chronic  metritis, 
Avhether  a  chronic  or  the  acute  affection  from  the  start,  is  an  inflamma- 
tory disease.  There  are,  it  is  claimed,  the  subjective  and  objective 
symptoms  of  inflammation — pain,  hypersesthesia,  heat,  redness,  and 
swelling.  There  are  enlarged  and  multiplied  blood-vessels ;  lowered 
vascular  tension ;  venous  stasis  ;  dilated  lymph-vessels  ;  emigration  of 
the  leucocytes ;  transudation  of  nutritive  plasma ;  secretion,  even  pus,, 
upon  the  free  surfaces ;  organization  of  connective  tissue ;  impaired 
nutrition — conditions  typical  of  chronic  inflammation. 

It  is  impossible  to  determine  at  the  bedside  exactly  when  the  state 
of  subinvolution  commences  to  merge  into  that  of  hyperplasia — a  slow 
and  insidious  development.  The  two  affections,  to  clinical  appearances,, 
resemble  each  other,  and,  apart  from  the  history,  differentiation  is 
obscure. 

Just  as  the  hypersemia  of  subinvolution  proves  so  potent  a  factor  in 
this  disease,  so  may  habitual  hypersemia  of  the  uterus  from  any  cause 
lead  to  the  hyperplasia.  To  a  very  great  extent  hyperplasia  is  limited 
to  the  parous  uterus.  The  normally  firm,  resisting  walls  of  the  nullip- 
arous  organ  afford  a  strong  resistance  to  expansion,  whether  by  vascu- 
lar fulness  or  cellular  proliferation.  Still,  it  is  not  to  be  forgotten  that 
this  disease  may  and  does  occur  in  the  nulliparous  organ. 

Etiology. — The  tendency  of  the  uterus  to  fluxion^  and  congestion^ 
is  obvious,  and  is  due  to — (a)  excessive  development  of  its  vascular, 
especially  venous  system,  these  veins  having  no  valves ;  (6)  the  erectile 
character  of  its  tissues,  favoring  stasis ;  (c)  the  low  position  of  the 
organ;  (d)  pressure  upon  it  by  abdominal  and  pelvic  viscera;  (e)  peri- 
odical influxes  of  blood  and  hemorrhages ;  (/)  enormous  hypertrophy 
from  pregnancy. 

All  the  causes  may  be  grouped  under  two  heads :  1.  Those  which 
interfere  with  the  normal  involution  of  the  puerperal  uterus  at  term  or 
after  abortions ;  2.  Those  which  produce  repeated  or  habitual  hyper- 
semia of  the  uterus. 

Under  the  first  head  are — contusions  and  lacerations  of  the  cervix  ; 
retention  of  the  products  of  conception,  as  placental  masses,  membranes,^ 
or  blood-clots ;  various  metritic  and  perimetritic  inflammations  after 

^  Fluxion  is  a  temporary  accumulation  of  blood,  rapidly  appearing  and  disappearing. 
^  Congestion  is  a  more  permanent  accumulation  of  blood  in  the  vessels,  and  may 
result  from  fluxion  often  repeated  or  strong. 


L'liiiosic  mj:ii:itis,  ktc.  of  riii:  rTr:i:rs:  (in:; 

|)ai"tiiriti(>ii  ;  too  early  I'isiiiiX  nih'V  laltur  or  alxiitimi  ;  iiiiii-la<tatiiiii  ; 
alxiit  iiiii. 

All  ol' tlioc  cair^'^  iiii|>lv  (•oiitlitiKii'.  wliicli  arc  liillowrd  l)\-  IocmI  cmi- 
ir«'>tii»iis.  roil  cariv  r('siiiii|iti<iii  of  tlu-  cri'ft  po-liirr  lead-  to  piL-.-ivo 
col  litest  ion  in  an  «'nlai";^('<l,  tlal)l>y  oiyan,  arrcstinii;  involution.  Tlic 
pliysiolojrjfnl  tlotcrtnination  of  Mood  to  the  Mianiniary  L;land>  in  lacta- 
tion cxiTciscs  a  derivative  inHnence  over  tlie  pelvic  orjians.  'I'lic  direct 
application  of"  the  cliild  to  the  hreast  rcHcxIy  excites  nterine  contraction, 
f'avoriiiu-  involution.  Involution  is  relatively  more  tardy  alter  ahonions, 
in  that  patients  do  not  aiterward  ohsi-rve  the  same  amount  ol"  i-e.-t,  and 
there  is  the  absence  of"  the  stimulus  <tf  lactation. 

Under  the  second  head  are  iucludetl — chronic  endometritis,  cervical, 
C()rporeal,  or  *»;eneral ;  versions  and  Hexions  ot"  the  uterus  ;  pressure  of 
certain  pelvic  or  alxlominal  tumors;  chronic  cardiac,  hepatic,  and 
nephritic  diseases ;  frequent  and  excessive  coitus  ;  constipation  ;  faulty 
Uodily  postures;  prolonged  standing;  wearing  around  tlie  waist  (jf 
tight  and   heavy  clothing,  etc, 

Chronic  endometritis  may  be  of  long  standing  in  the  nullipara,  and 
not  lead  to  any  special  hypertemia  of  the  parenchyma.  Not  so  if  in 
the  multipara.  The  ditt'crcnce  in  results  is  owing  to  the  difference  in 
the  tissues  of  the  parenchyma  in  the  two — in  the  one  firm  and  resist- 
injr ;  in  the  other  more  soft  and  vielding. 

Versions  and  flexions  almost  always  are  secondary  to  increased  bulk 
and  weight  of  the  uterus,  with  its  attendant  chronic  congestion.  In 
turn,  these  displacements  so  interfere  with  the  venous  flow  that  there  is 
conscfjuent  passive  hypersemia.  Either  wall  or  a  portion  of  the  uterus, 
according  to  the  kind  and  degree  of  displacement,  may  take  on  hyper- 
plastic thickening  and  induration  ;  for  instance,  it  is  the  upper  and  pos- 
terior wall  which  is  involved  in  retroflexion. 

Any  tumor  within  the  walls  or  any  outgrowth  of  the  uterus  or  its 
appendages  may,  by  virtue  of  its  size  or  position,  so  obstruct  the  venous 
circulation  as  t(j  produce  great  venous  engorgement.  The  presence  of 
any  tuin(jr  directly  invites  and  keeps  up  a  developmental  attraction  of 
blood. 

Chronic  valvular  diseases  of  the  heart,  chronic  interstitial  changes  in 
the  liver,  impede  the  portal,  then  the  pelvic  circulation  ;  hence  they  are 
attended  by  uterine  hy]ierjemia  of  a  passive  kind.  AVomen  who  are 
suijjects  of  diabetes  are  particularly  prone  to  chronic  uterine  congestion. 

Congestion  and  inflammation  of  the  ovaries  provoke  augmented 
blood-accunudation  in  the  uterus.  Just  as  the  initial  physiohtgical 
act  of  menstruation  is  commenced  in  the  ovary,  and  thence  propagate<l 
to  the  uterus,  so  certain  morbid  .states  of  these  organs  lead  ultimate- 
ly to  uterine  congestion  which  may  terminate  in  hemorrhage  and 
enlaro:emcnt. 


604       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

Every  act  of  coitus  is  followed  by  some  acute  fluxion  of  blood  to  the 
internal  genitalia,  which  under  normal  restrictions  soon  passes  away. 
But  if  the  act  is  excessive  and  often  repeated  the  vascular  flilness 
becomes  permanent  and  pathological. 

Undue  meddlesomeness  of  local  treatment  with  the  speculum  or  cau- 
terization may  perpetuate  the  very  condition  of  chronic  hypersemia 
Avhich  it  is  intended  to  remove. 

The  condition  of  the  pelvic  circulation,  especially  in  women,  is 
modified  in  manifold  ways  by  the  general  bodily  condition.  Imper- 
fect general  health,  defective  nutrition,  and  sluggish  circulation  in  gen- 
eral imply  low  arterial  tension  and  favor  pelvic  venous  stasis.  The 
female  pelvis  may  thus  be  compared  to  a  reservoir  of  great  blood- 
capacity,  the  quantity  of  its  contents  being  subject  to  remarkable 
fluctuations  by  virtue  of  various  mental  states,  bodily  conditions, 
and  positions. 

In  conclusion,  as  chronic  metritis  takes  its  origin  in  hypersemia  from 
any  cause,  it  may  be  stated  that  whatever  conduces  toward  the  accumu- 
lation and  retardation  in  the  uterine  or  utero-ovarian  vessels  leads 
directly  to  the  different  stages  of  the  disease  in  question.  The  proxi- 
mate cause  in  all  cases  is  an  excess  of  venous  blood  in  the  endometrium 
and  parenchyma. 

Frequency. — In  view  of  the  foregoing  causative  influences,  pre- 
disposing and  direct,  it  is  not  a  matter  of  surprise  that  this  is  an  affec- 
tion of  great  frequency.  Probably  more  than  50  per  cent,  of  all  women 
presenting  themselves  for  local  treatment  show  evidences  of  it  in  some 
degree.     Its  importance,  then,  cannot  be  over-estimated. 

Varieties. — Chronic  metritis — chronic  hypersemia  and  hyperplasia 
— may  involve  any  portion  of  the  uterus,  neck  or  body,  or  certain  por- 
tions thereof.  For  manifest  reasons  the  neck  of  the  uterus  is  the 
favorite  habitat.  The  extreme  liability  of  this  portion  of  the  organ 
to  injury  by  contusion  and  laceration  in  parturition ;  to  friction  in 
coitus  or  by  displacement;  its  dependency,  favoring  gravitation  of 
blood  within  its  structures ;  the  relatively  increased  frequency  of  cer- 
vical endometritis  over  the  kindred  affection  of  the  body, — these  may 
be  mentioned  as  among  the  more  important  reasons.  Involution  from 
some  of  these  causes  may  be  incomplete  in  the  neck,  while  perfected  in 
the  body,  of  the  uterus. 

Hyperplasia  may  be  localized  largely  within  either  wall  of  the  neck 
or  body.  If  in  the  former,  it  is  generally  the  anterior  lip  which  is 
affected ;  if  in  the  latter,  it  is  the  posterior  wall  which  is  more  fre- 
quently implicated,  simulating  fibroid  infiltration.  To  the  more  fre- 
quent implantation  of  the  placenta  on  the  hinder  wall  and  consequent 
increased  risks  of  delayed  involution,  and  to  the  fact  that  retroversion 


CHRONIC  METRITIS,  ETC.   OF  Till:   UTERUS.  G05 

is   one   t>l"  the    iiiost    (•(Hiiiiuni    roiMiis  (if  tli>itl;icciii('iit    alter   |»:ir(m-it  ioii, 
iiiav    1)('  attriltiitcd   this  s|K'cial    Incali/.atioii. 

SvM  I'roMAi'ol.ncN'. — 'PluTc  art-  no  ^\  iii|)t<tiiis  in  clii'uiiic  metritis 
initliofiiioinonic  of  it,  none  that  1k'1()Ii<j;  cxchisivcly  to  it,  none  hut  what 
arc  found  in  othei-  chronic  pelvic  (especially  uterine)  intlanunations. 
Manvofthe  sviu|)tonis  arc  dependent  lart^ciy  upon  the  degree  of  hypei- 
teinia,  with  (he  increased  hulk  and  weight  of  the  uterus.  Others  result 
from  certain  complications,  such  as  chronic  endometritis,  almost  con- 
stnntlv  present.  The  nu)st  common  local  symptoms,  which  in  a  great 
pr(i])ortion  of  cases  date  hack  to  a  confinement,  are  sensations  of 
iicaviness,  weight,  and  dragging  within  the  j)elvis,  aggravated  hy  walk- 
iiiir,  standing,  and  the  approach  of  menstruation.  The  performance  of 
this  last-named  function  necessarily  augments  the  local  hlo()d-su])ply, 
increases  the  uterine  weight,  and  consequently  the  tension  upon  the 
utei'ine  ligaments. 

Aside  from  these  symptoms,  resultant  directly  on  excessive  vascular 
fulness,  there  is  pain,  traceable  to  the  structural  changes  going  on  in 
the  parenchyma,  leading  to  pressure  upon  the  nerves.  The  uterus  is 
hyper£esthetic.  Pains  radiate  to  the  back,  loins,  limbs,  and  distant 
parts  of  the  body. 

Urination  and  defecation  may  now  be  made  frequent  and  })ainful  by 
direct  pressure  of  the  enlarged  uterus  upon  the  bladder  and  rectum,  by 
congestion  of  these  organs,  or  by  a  sympathetic  irritation.  Vesical 
irritability  is  sometimes  one  of  the  most  annoying  of  all  symptoms. 
Coccygodynia,  usually  a  neurosis,  is  another  sample  of  reflex  uterine 
irritation.  There  is  often  dyspareunia.  Leucorrhoea  is,  as  a  rule, 
present  on  account  of  coexisting  endometritis.  The  menstrual  func- 
tion will  be  disturbed  in  time,  duration,  quantity,  or  quality  according 
to  the  stage  of  the  disease,  the  degree  of  hyperoemia,  and  the  portion  of 
the  organ  Avhich  is  especially  involved.  At  the  beginning,  -when  hypcr- 
a^nia  is  the  controlling  pathological  state,  whether  from  subinvolution 
or  otherwise,  menstruation  will  be  profuse,  ]irolonged,  or  too  frequent. 
Gradually,  as  hyperemia  diminishes,  resultant  on  the  growth  of  the 
connective  tissue,  the  uterus  becoming  harder  and  denser,  the  menstrual 
flow  will  be  less  free  until  it  is  scant,  or  may  after  years  become  very 
irregular  and  cease  altogether.  A  premature  so-called  "change  of  life" 
is  thus  brought  about.  A  dull  aching  pain  through  the  uterine  region 
— congestive  dvsmenorrhoea — is  often  experienced,  conmiencing  a  few 
days  prior  to  the  menstrual  flow  and  increasing  until  it  is  well  estab- 
lished.    It  is  usTially  relieved  by  the  depletion  of  the  flow. 

All  of  these  local  svmptoms  are  agirravated  by  the  occurrence  of  any 
serious  amount  of  displacement.  They  are  likewise  more  pronomiccd 
Avhen  the  body  of  the  uterus  instead  of  its  neck  is  the  seat  of  the 
disease. 


606       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

The  reproductive  functions  are  affected  in  various  ways.  Subinvo- 
lution and  early  chronic  metritis  appear  rather  to  favor  pregnancy, 
though  abortions  are  more  apt  to  follow.  Each  abortion  adds  to  the 
original  difficulty,  leaving  the  uterus  larger,  heavier,  and  more  vascular 
than  before.  Advanced  stages  of  hyperplasia  and  sclerosis  are  attended 
with  sterility.  Pregnancy  completed,  parturition  normal,  a  prolonged, 
careful  attention  during  the  lying-in  state  doubtless  will  do  much  to 
improve  the  morbid  condition  of  the  uterus  previously  existing. 

The  general  symptoms  have  reference  to  the  disorders  of  digestion, 
nutrition,  and  especially  to  disturbed  functions  of  the  nervous  system. 
There  is  dyspepsia;  the  bowels  are  constipated;  the  body  loses  weight; 
there  are  feelings  of  languor  and  weakness.  There  are  fretfulness,  irri- 
tability of  temper,  melancholia,  and  sleeplessness.  The  various  reflex 
or  sympathetic  disorders  are  more  often  manifest  in  chronic  metritis 
than  in  any  endometrial  disease.  Thus,  the  stomach  is  quite  often 
made  irritable  in  the  form  of  nausea  and  vomiting.  The  mammary 
glands  are  enlarged,  nodulated,  and  tender,  especially  preceding  and 
during  menstrual  periods.  The  abdomen  is  flatulent,  distended,  and 
the  seat  of  various  irregular  muscular  actions.  It  is  in  this  disease, 
after  long  continuance,  more  particularly  approaching  the  climacteric 
period,  that  we  more  commonly  witness  the  symptoms  of  pseudo- 
cyesis  and  phantom  tumors.  If  prolonged  into  these  years  of  cli- 
macteric change,  all  the  nervous  disorders  so  characteristic  of  this 
epoch  are  more  early  and  strikingly  displayed. 

Hysterical  symptoms  are  among  the  more  important  of  the  compli- 
cations of  the  nervous  system,  and  they  are  produced  in  every  varying 
degree  and  form. 

Headaches  of  the  nervous  and  congestive  varieties  are  the  source  of 
much  suffering  to  many  women.  As  the  patient  nears  the  menopause, 
and  especially  when  the  menstrual  flux  is  becoming  irregular  and  scant, 
the  brain  is  prone  to  receive  the  impress  of  the  undue  vascular  tension. 
Each  period  is  preceded  or  accompanied  by  a  flushed  face,  throbbing 
temples,  and  dull  aching  pain  in  the  head. 

Chloasma  uterinum,  a  symptomatic  pigmentation  with  broAvnish 
spots  or  patches  distributed  over  the  face,  is  most  pronounced  in 
brunettes  and  at  the  menstrual  periods.  These  discolorations  are 
not  confined  to  this  disease,  inasmuch  as  they  may  be  present  as  a 
result  of  various  menstrual  disturbances  without  any  organic  lesions. 

Physical,  Signs  and  Diagnosis. — The  uterus  will  be  found  to  be 
enlarged,  swollen,  and  sensitive.  In  the  stage  of  subinvolution  and 
hypersemia  these  signs  are  apparent.  The  walls  also  are  softer,  flabby, 
and  on  inspection  present  the  appearance  of  increased  vascularity,  usu- 
ally of  the  passive  variety.     The  enlargement  is  uniform. 

In  the  second  stage  (hyperplasia)  the  uterine  walls  are  still  sensitive, 


ciinosic  MirrniTis,  etc.  of  tiii:  rrEiirs.  (jo? 

but  hanl,  (Iciise,  (>iilar<rc<l,  usually  syiimictrirally,  hut  tiiavhc  irrc;^!!- 
larly,  in  either  wall  nf  the  iie<l<  or  hudy.  Irrejxiihirities  in  .slia|M'  an<l 
iioihihitiuns  tVoiii  hy|)ei'|»hi>ia  are  iim-tly  toiiiid  where  the  parts  are  fis- 
sured from  iaet'i'atious.  Owiu^i"  to  increased  hulk  and  wei<;iit  the  uterus 
is  verv  often  (Us|)hieed  downwardly,  ■without,  it  may  he,  any  elianjre  in 
its  axis  ;  j)osteriorl\-  with  almost  equal  fre(|Ueney.  The  os  is  patulous, 
adiuittini::  the  tip  of  the  index  Hn^er.  The  sound  shows  increased 
measurement,  ."]  to  -'U  or  4  inches,  passes  with  *:;reat  facility,  and  moves 
freely  in  the  roomy  upper  cavity.  This  exploration  detects  the  decree 
of  sensitiveness,  and  is  followed  hy  a  dull  acliin;::  pain. 

As  hyperplasia  may  be  localized  to  the  cervix,  corpus  uteri,  or  be 
penoral,  its  exact  seat  is  revealed  by  vaginal  and  rectal  touch,  specular, 
bimanual,  and  sound  explorations. 

Chronic  metritis  may  be  confounded  with  early  })re,L!;nancy,  small 
fibroid  tumors,  and  scirrhus  of  the  cervix. 

Diti'erentiation  between  chronic  hypcraemia  with  hyperj)l;L<ia  and 
prcirnaucy  is  sometimes  obscure,  on  account  of  the  marked  resem- 
blance in  many  of  the  general  symptoms  and  physical  signs.  In  the 
former,  however,  menstruation  very  rarely  ceases,  though  it  may  be 
irregular,  and  the  uterus  is  very  sensitive  to  touch. 

If  conception  should  take  place  in  a  uterus  previously  the  seat  of 
this  disease  while  possibly  the  patient  is  under  treatment,  confusion  is 
further  increased.  In  all  cases  of  doubt  the  use  of  the  sound  as  a 
means  of  diagnosis,  a.s  well  as  all  intra-uterine  treatment,  should  l^e 
omitted,  until  at  least  further  developments  settle  the  diagnosis.  If 
pregnancy  exists,  a  few  weeks  will  so  alter  the  size,  shape,  and  position 
of  the  uterus  that  the  real  condition  generally  becomes  clearly  revealed. 

Likewise,  fibroid  tumors  of  small  size,  developing  within  either  ute- 
rine wall  or  creating  a  symmetrical  enlargement  of  the  whole  organ,  pre- 
sent physical  signs  calculated  to  mislead.  Cimclusions  may  be  based  on 
the  menstrual  history  and  such  signs  as  are  elicited  by  touch,  the  use 
of  tents,  the  sound,  and  conjoined  manipulation. 

Again,  chronic  hyperplasias  with  marke<l  induration  may  offer  sus- 
]iic-ious  evidences  of  cancerous  infiltration  of  the  infravaginal  cervix. 
The  imjiortance  of  a  correct  diagnosis  is  very  great,  but  this  is  at  times 
\QTy  difficult.  If  the  general  health  is  declining  and  there  is  cachexia, 
the  patient  being  advanced  in  years,  and  if  there  is  menorrhagia,  the 
evidence  leans  toward  cancer.  If  the  history  points  back  to  ]>arturi- 
tion,  the  local  condition  having  been  preceded  by  symptoms  of  chronic 
uterine  inflammation,  and  there  is  a  tendency  toward  amenorrhcea,  the 
disease  is  probably  not  cancerous. 

iSpiegelberg  has  offered  a  method  of  diagnosis  wliich  certainlv  is  val- 
uable in  the  early  stages  of  carcinoma,  prior  to  destruction  of  any  tissue 
in  the  mucous  membrane.     Thus — 


608       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

1 .  The  mucous  membrane  in  a  cancerous  gro-s^i:!!  is  firmly  connected 
with  the  underlying  induration,  and  immovable  over  it,  which  is  not 
the  case  in  mere  hyperplastic  thickening  and  induration. 

2.  The  latter,  under  the  pressure  of  compressed  sponge  in  the  cer- 
vical canal,  becomes  regularly  (even  though  at  times  inconsiderably) 
looser,  softer,  and  thinner ;  the  cancerous  infiltration  remains  unalter- 
ably hard  and  rigid,  and  cannot  be  stretched. 

Localized  hyperplasia  of  the  anterior  wall  simulates  anteflexion  ; 
of  the  posterior  wall,  retroflexion.  The  sound  is  the  means  of 
diagnosis. 

PROaxosiS. — This  is  for  the  most  part  favoraljle,  but  is  influenced 
to  a  great  degree  by  the  portion  of  the  uterus,  neck  or  body,  which  is 
affected,  and  also  by  our  opportunity  to  remove  the  causative  hyper- 
semia.  Prognosis  is  much  more  favorable  when  the  neck  is  the  seat 
of  the  disease  and  the  body  is  not  implicated,  for  the  reason  that  the 
svmptoms  are  less  grave,  the  disease  is  more  easily  attacked  by  local 
treatment,  and,  finally,  the  parts  are  much  less  sensitive  to  local  inter- 
ference. 

If  the  cause  cannot  be  removed,  palliation  alone  is  possible.  Persist- 
ent hvpersemia  produced  by  an  incurable  chronic  cardiac  or  hepatic  dis- 
ease or  pelvic  tumor  is  susceptible  only  of  amelioration. 

Recovery  is  commonly  tedious,  and  the  patience  of  both  practitioner 
and  patient  is  sometimes  severely  taxed.  It  is  not  possible  to  directly 
remove  or  create  any  absorption  of  the  proliferating  connective  tissue. 
The  chronic  congestion  can  generally  be  cured  if  its  cause  can  be 
removed ;  always  may  it  be  diminished  by  local  and  constitutional 
measures.  Its  abatement  may  be  the  means  toward  an  arrest  of  the 
hyperplastic  changes. 

The  approach  of  the  menopause  is  usually  a  favorable  factor  in  prog- 
nosis, for  at  this  time  the  vitality  and  vascularity  of  the  generative 
organs  gradually  lessen. 

The  amount,  kind,  and  degree  of  complications  materially  modify 
results.  Coexistent  displacements,  chronic  cellulitis,  ovaritis,  and  cys- 
titis present  important  and  serious  barriers  to  a  successful  issue. 

May  the  morbid  tissues  of  chronic  metritis  be  transformed  in  cancer- 
ous formations?  ISToeggerath  has  reported  several  instances  favoring 
this  view.  The  experience  of  most  gynecologists  is  to  the  contrary. 
Klob  expresses  himself  thus :  "  What  has  been  said  by  various  authors 
on  the  relations  of  difPase  growth  of  connective  tissue  to  the  develop- 
ment of  carcinoma  must  be  considered  a  mere  h^-ioothesis."  But  these 
benign  alterations  in  structure  may,  in  such  as  are  predisposed  Ijy  the 
local  irritation  produced,  indirectly  conduce  to  the  development  of 
malignancy  of  groAvth.  Particularly  is  this  so  when  the  hyperplastic 
formations  are  attendant  on  lacerations  of  the  cervix. 


CJih'nMc  Mjrnn'j'is,  i:t<:  of  tii/-:  rriiiiun.  gou 

TIk'  pliysiciim  is  (it'tcii  a-kcil,  What  iiilliiciicc  will  |(rc:^iiaii<-\'  ami 
parturition  have  on  tin-  local  <'oii(litioii>  of  clironic  nirtritis  V  In  nianv 
instances,  donhtlcss,  tlic  inllncncc,  il"  any,  is  injnrions.  Not  onlv  inav 
tlic  solt  pails  he  lorn  in  (lie  (Iclivny,  lint  the  snlwipu-nt  involntion 
may  !«'  made  more  iniju'rlcct.  'V\\v.  ntcrns  rmiainin;^'  larjx<'r,  its  snj)- 
ports  aic  li'ss  adcMpiati' to  pcrlorin  tiu-ir  f'lniction,  and  the  orj^an  heconjes 
iurtlicr  disphu'cil.  Siu'li  is  by  no  moans  necessarily  the  case:  pregnancy, 
partnrition,  and  the  lyin<»-in  state  may  he  so  eonchicted  that  an  nnnsnal 
o|)|)ortnnily  is  atlorded  to  accomplish  a  degree  of"  good  \\hi<'h  can  he 
attained  in  no  other  niainicr.  A  natural  deliyery,  with  tlu;  integrity 
oi'  the  parts  unimpaired;  a  prolonged  decubitus  free  from  sepsis;  the 
ailminstration  of  yaginal  injections  to  secure  perfect  cleanliness;  ergot 
and  quinine  to  secure  thorough  tonic  contractions  of  the  uterus;  the 
suckling  of  the  infant;  careful  return  to  ordinary  exertion,  etc., — 
are  some  of  the  means  which  may  bring  about  a  complete  transfor- 
mation. 

As  interstitial  fibroid  tumors,  if  not  of  too  large  proportions,  haye 
undergone  absorption,  since  their  structure  is  homologous  to  the  uterine 
tissue  proper,  so,  without  question,  there  is  reason  to  expect  that  hyper- 
trophied  cellular  tissue  from  chronic  metritis  may  likewise  be  cauuht 
into  the  processes  of  absorption  in  normal  inyolution  after  parturi- 
tion, and  be  thus  removed. 

Complications. — The  most  common  complications  are  chronic 
endometritis,  vaginitis,  yersions  and  flexions,  pelvic  cellulitis  and  peri- 
tonitis, and  ovaritis.  In  point  of  frequency  this  is  the  order  of  occur- 
rence. So  frequently  does  chronic  endometritis  exist  as  a  complication 
that  it  is  seldom,  if  ever,  entirely  absent.  In  Avhatever  way  or  form 
chronic  metritis  is  developed,  the  starting-point  of  the  disease  is  almost 
invariably  in  the  endometrium. 

TuEATMENT. — It  is  evident  at  the  start  that  a  clear  and  correct 
understanding  of  the  etiology  and  pathology  of  chronic  metritis  is  of 
the  utmost  importance  to  comprehend  the  principles  Mhich  underlie  its 
management.  H(jw  misguiding  such  terms  as  "  irritable  uterus," 
^'  chronic  hypertrophy  of  the  uterus,"  are  is  apparent.  We  must  bear 
in  mind  that  chronic  metritis,  so  called — except  in  rare  instances,  after 
acute  puerperal  parenchymatous  metritis — is  not  a  chronic  stage  of  an 
antecedent  acute  inflammation.  We  must  also  endeavor  to  detect  which 
stage  of  the  disease  is  present  or  predominant. 

Treatment  is  both  constitutional  and  local.  As  uterine  congestion 
complicates  or  plays  a  most  important  role  in  a  large  proportion  of  all 
cases  of  chronic  uterine  disease,  constituting  the  greatest  and  most  serious 
obstacle  to  cure,  it  follows  that  the  chief  aim  and  oliject  of  treatment  in  this 
disease  is  to  diminish  and  prevent  the  same.  It  may  be  laid  down  as 
a  cardinal  principle  that  there  can  be  no  permanent  improvement  until 

Vol.  I.— 3U 


610       THE  INFLAMMATORY  AFFECTIONS   OF  THE    UTERUS. 

the  pelvic  circulation  is  improved  by  a  restoration  of  the  tone  of  the 
blood-vessels.     In  various  ways  may  this  end  be  secured. 

General  Treatment. — Rest. — Such  exercises  as  dancing,  horseback 
riding,  much  carriage  and  street-car  riding,  ascending  stairs,  prolonged 
standing,  the  use  of  the  sewing-machine,  etc.,  which  incite  pelvic  con- 
gestion, should  be  avoided.  The  patient  should  be  instructed  to  lie 
down  for  a  few  hours  in  the  middle  of  each  day,  the  garments  around, 
the  waist  in  the  mean  time  being  well  loosened.  The  horizontal  pos- 
ture favors  by  gravity  the  partial  emptying  of  the  engorged  blood- 
vessels and  diminishes  pain.  The  necessity  for  such  periods  of  rest  is 
most  urgent  as  the  menstrual  epoch  approaches  and  continues.  Exacer- 
bations of  fluxion  occur  at  these  times ;  hence  much  can  be  done  by 
judicious  care  in  preventing  relapses.  But  there  is  always  danger  that 
the  strict  enjoining  of  rest  may  lead  to  its  abuse.  Rest  becomes  injurious 
when  unduly  prolonged,  as  it  interferes  with  digestion,  circulation,  and 
nutrition.  A  certain  amount  of  exercise — walking  in  the  open  air — 
should  therefore  be  carefully  observed, 

Xot  only  rest  by  posture,  but  rest  in  its  general  sense,  should  be 
enforced.  This  implies  freedom  from  excitement  of  all  kinds,  and  the 
avoidance,  if  possible,  of  all  causes  of  mental  depression.  Sexual  inter- 
course is  a  frequent  source  of  aggravation  and  perpetuation  of  uterine 
congestion,  Nothing  can  operate  more  injuriously  in  maintaining  local 
pain,  interfering  with  the  otherwise  successful  progress  of  a  case,  than 
frequent  coition.  If  not  entirely  abstained  from,  it  should  be  indulged 
in  at  long  intervals  only. 

The  beneficial  eifects  of  rest  in  its  fullest  sense — physical  and  men- 
tal— are  at  times  well  illustrated  by  a  removal  of  the  patient  to,  and  a 
sojourn  at,  the  seaside,  the  mountains,  or  some  well-selected  mineral 
springs.  The  change  of  air,  diet,  scenery,  and  associations,  the  pres- 
ence of  cheerful  company,  the  absence  of  domestic  care  and  anxiety,  the 
freedom  from  coition,  are  powerful  means  in  the  restoration  of  the  gen- 
eral health,  and  with  it  an  improvement  in  the  local  conditions.  The 
influence  of  such  forces  durmg  a  sojourn  at  mineral  springs  has  more 
to  do  in  restoring  the  health  of  many  invalid  women  than  the  use  of 
the  waters  by  drinking  or  bathing.  Not  that,  however,  the  mineral 
waters  are  to  be  ignored.  Certain  of  them  are  most  beneficial  in 
improving  the  appetite,  correcting  indigestion,  and  promoting  secre- 
tion and  excretion.  On  the  Continent  the  best  are  Kreuznach  (iodo- 
bromated),  Schwalbach,  INIarienbad,  Carlsbad,  Kissingen,  Weisbaden, 
and  Baden-Baden ;  in  the  United  Sates,  the  Saratoga  (N.  Y.),  White 
Sulphur  (W.  Va.),  Blue  Lick  (Ky.),  Hot  and  Warm  Springs  (Va.), 
and  Rockbridge  Alum  Springs  (Va.). 

Weir  Mitchell  has  introduced  and  practised  a  scientific  system  of 
enforced  rest  in  conjunction  with  full  diet,  massage,  and  electricity. 


cnnnsic  MF/niiTis,  irn:  or  riih:  i"n:nrs.  (ill 

Tilt'  Mit<'li<ll  |>l;iii  III  inatiMciit  i-  »-|)('cially  a(la|)tc(l  to  tiisi's  (»f  foii- 
Hniicd  lu'iirastlifiiia  and  l»yst«'ria  in  its  inatiifnld  loi-ni-  (IcjH-ndcnt  or 
not   n|)on   chronic  uterine  diseases. 

J),r.-<s. — 'i'lu'  jrarinents  should  l)c  \\oi-n  loosely  around  the  waist,  and 
their  weight  shoidd  he  as  lij:ht  as  is  consistent  with  warmth.  Ti<rht- 
tittinii"  corsets  and  skirts,  iniju'dinir  as  they  do  the  alKloiuinal  circulation 
and  de|)ressin<;  the  ahdoniinal  and  pelvic  viscera,  are  to  l)C  discarded. 
All  uarnicuts  hanuiuir  from  the  waist  should  be  suspendtKl  by  aj)i)roj)riate 
ai)i)aratus  from  the  shouhlcrs.  Instead  of  a  coi-set,  a  lifj:;ht,  well-futed 
waist  answers  for  this  purpose.  The  use  of  an  abdominal  bandage,  which 
will  \'\i\  the  abdominal  viscera  from  below  the  und)ilicus,  diminishes 
intraj)elvic  i)ressure  from  above,  and  is  not  unfrequently  a  source  of 
considerable  comfort  where  the  uterus  is  enlarged,  heavy,  and  dis- 
placed downward  or  forward.  High-heeled  shoes,  which  distort  the 
relations  of  the  body,  altering  the  natural  inclination  of  the  pelvis  to 
the  trunk,  should  be  rejected. 

Posfinr. — Posture  influences  in  a  most  marked  manner  the  pelvic 
circulation.  As  the  blood-pressure  is  increased  and  venous  stasis 
brought  about  by  faulty  position  of  the  bcxly  in  standing,  sitting,  and 
lying-down,  these  should  be  corrected. 

Attenfion  to  the  Boweh. — Especial  attention  should  be  directed  toward 
acquiring  a  free  alvine  evacuation  daily  and  the  regulation  of  the  func- 
tions of  the  chylopoietic  viscera,  as  constipation  and  obstruction  in  the 
])ortal  circulation  always  hinder  circulation  in  the  pelvic  blood-vessels. 
The  selection  of  the  necessary  medicine  depends  upon  the  condition  and 
constitution  of  the  individual.  An  occasional  mercurial,  followed  by 
a  saline  purge,  answers  a  good  purpose  in  those  sufficiently  strong,  when 
the  tongue  is  furred,  the  portal  circulation  torpid,  and  there  is  constipa- 
tion. The  salines,  sulphate  of  magnesia,  Carlsbad  salts,  etc.,  in  small 
quantities,  well  diluted,  in  the  morning  fasting,  are  well  adapted  to 
many  cases.  The  various  mineral  waters,  Kissingen,  Marienbad, 
Hathorn,  Congress.  Hunyadi,  are  convenient  agents  for  similar  pur- 
poses of  promoting  secretions  and  giving  freer  intestinal  movements. 

Others  are  best  suited  by  the  vegetable  laxatives,  podophyllin,  colo- 
cynth,  aloes,  etc.,  in  small  doses.  Diet  should  not  be  neglectcxl.  Fuller 
directions  for  the  relief  of  constipation  will  be  given  under  the  consti- 
tutional treatment  of  chronic  uterine  diseases. 

Special  Medication. — Certain  medicinal  remedies  are  known  to  influ- 
ence the  uterine  circulation  and  diminish  its  vascular  fulness.  X(»tably 
among  these  stands  ergot ;  inferior  to  it,  but  not  unimportant  remedies, 
are  quinine,  nux  vomica,  and  the  bromides.  Ergot,  in  the  form  of  the 
fluid  extract,  or  ergotin  should  be  administere<l  three  times  daily  in 
cases  of  subinvolution  and  in  the  stages  of  hyperaemia  following ;  in 
fact,  so  long  as  increased  vasc-ularity  remains  the  chief  local  pathologi- 


612       THE  INFLAMMATORY  AFFECTIONS  OF  THE    UTERUS. 

cal  factor  of  the  disease.  If  the  stomach  becomes  intolerant  of  its  inges- 
tion, suppositories  per  rectum  may  be  substituted  or  the  remedy  may  be 
given  hypodermatically.  Ergot  tends  to  contract  the  fibres  of  the  uterine 
wall,  the  unstriped  fibres  of  the  blood-vessels,  and  in  this  way  dimin- 
ishes congestion.  Thus,  its  use  is  indicated  during  the  menstrual  period 
if  there  is  menorrhagia,  and  during  the  interval  for  its  more  permanent 
efPects  on  the  affected  structure.  The  virtues  of  ergotin  are  enhanced 
by  a  combination  with  quinine  and  nux  vomica.  A  favorite  pill  with 
the  author  is — 

I^.  Ergotinse,  9jss ; 

Quininse  sulphatis,  Bjss ; 

Extracti  nucis  vomicae,  grs.  viii. 
M.  Ft.  mas.  in  pil.  xxx.  Div. 
Sig.  A  pill  three  times  a  day. 

When  hyperplasia  has  well  advanced  ergot  is  useless. 

The  potassic  and  soclic  bromides  act  with  signal  benefit  in  some  men- 
orrhagic  conditions  dependent  upon  uterine  congestion.  They  are 
equally  useful  to  control  certain  reflex  disorders. 

Some  practitioners  have  praised  the  virtues  of  the  mercuric  bichlo- 
ride and  the  auric  and  sodic  chloride,  given  in  minute  doses,  continued 
for  a  long  time  in  chronic  metritis.  It  is  even  claimed  that  they  have 
the  power  to  check  and  diminish  hyperplastic  infiltrations.  Probably 
they  are  worthy  of  further  trials  in  these  directions.  At  any  rate,  the 
potassic  iodide  and  the  mercuric  bichloride  are  valuable  remedies  at  times 
in  this  disease  prior  to  much  hyperplastic  change,  remarkably  improv- 
ing the  general  health,  although  there  is  no  specific  constitutional  taint. 
The  mercuric  bichloride,  in  minute  doses  long  continued,  often  proves 
an  excellent  tonic,  eveu  increasing  the  number  of  red  blood-corpuscles. 
When  parametritic  inflammatory  exudations  are  present  these  remedies 
are  especially  indicated. 

The  prescribing  of  iron  where  there  is  early  chronic  metritis  is  a  mis- 
take too  frequently  made.  All  the  chalybeate  preparations  promote 
pelvic  congestion  in  either  sex.  The  objections  to  their  use  are  founded 
on  experience.  As  a  rule,  iron  is  contraindicated  ;  certainly  it  should 
rarely  be  given  in  the  first  stage  and  the  first  half  of  the  second  stage  of 
the  disease,  although  there  is  ansemia.  Under  its  use  the  author  has  very 
often  observed  the  menstrual  periods  made  profuse,  prolonged,  and  the 
local  conditions  aggravated.  Toward  the  stage  of  atroj)hy  or  sclerosis  with 
scant  menstruation,  iron  is  admissible  if  the  general  conditions  indicate  it. 

Arsenicum  (Fowler's  solution),  three  drops,  with  water,  after  meals, 
is  frequently  beneficial  when  there  are  contraindications  for  the  use  of 
the  chalybeate  preparations.  When  the  menstrual  function  is  too  fre- 
quent, too  long,  and  too  free,  these  disorders  may  sometimes  be  corrected 
by  the  persistent  use  of  arsenic. 


ciinoMc  M/rj/n'i'is,  ETC.  or  rin:  iii:i:rs.  ci;; 

Lociil  Trt  (ifiiiciil. —  I  iici'cascd  locil  liliiip(l->ii|)|)l\-  to  the  iitcni-  can  In; 
(limiiiislicd  l)\  — 

1.  I fol-iralcr  S'lK/iiKil  Injcc/ioiis. —  In  addition  to  kcc|)iii^  the  part.s 
clean,  tlicrcljv  |)r('\('iitiii!j,' secondary  vat;initis  and  vidvitis,  vaj^iiial  injec- 
tions (tf  liii;li  tcni|K'ratnr(',  n^vd  in  lariic  qnantities,  of  lon^- din-atioii  and 
with  steady  |)ei-scvei-a nee  while  llie  patient  is  in  the  dorsal  p(^sition,  are  a 
means  second  to  nonc^  to  contract  the  dilated  blood-vessels  and  inijirove 
the  local  circnlation. 

2.  IjOntl  hcjtictioit. — Tliis  can  he  pi'actised  \)\  one  ol'  lonr  methods — 
leechino',  pnnelin'inii;,  scai'ilication,  and  eii|)|>iiiii'.  'he  first  i>  thronuh 
a  cylindrical  ti'lass  specnluni  larg-e  c'lioniih  to  cn<2;a<i;e  the  whole  vaginal 
face  of  the  cervix,  which  is  first  cleaned  and  then  its  canal  plugtjed  with 
cotton  to  prevent  the  entrance  of  the  leeches  within  the  nterine  cavity. 
If  the  cervix  is  much  vascular  the  necessary  nuniher  of  leeches  (two  to 
four)  are  pushed  at  once  through  the  speculum  against  the  cervix.  On 
suspicion  that  blood  will  not  flow  freely  the  cervix  should  be  punctured 
slightly  before  the  leeches  are  placed  in  position.  The  leeches  are  per- 
mitted to  remain  until  filled,  the  cervix  sponged  with  warm  water,  and 
the  speculum  withdrawn.  Leeching  is  expensive,  troublesome,  requires 
much  time  if  well  done,  is  distasteful  to  the  patient,  and  the  bites  now 
and  then  bleed  too  freely  and  too  long,  and  create  much  pain.  In  con- 
sequence this  method  of  depletion  has  very  properly  been  almost  entirely 
superseded  by  puncturing  and  scarification. 

Puncturing,  if  done  thoroughly,  will  abstract  all  necessary  quantities 
of  blood  quickly  and  conveniently.  It  is  best  practised  by  a  spear- 
pointed  instrument  called  Buttle's  scarificator  (Fig.  198).     The  point 

Fig.  198. 


Buttle's  Spear-pointed  Puncturing  In.'^trumcnt. 


of  this  little  instrument  is  thrust  into  the  cervix  at  its  most  vascular 
points,  care  being  taken  not  to  wound  a  varicose  vein.  Each  puncture 
should  be  from  one-sixteenth  to  one-fourth  inch  or  more  in  depth, 
according  to  the  freedom  of  the  flow  of  blood  produced.  The  endeavor 
should  be  to  deplete  at  each  sitting  to  the  amount  of  one  to  two  fluid- 
ounces,  each  puncture  depleting,  on  an  average,  one  drachm.  Bleeding 
is  facilitated  by  sponging  the  surfaces  with  warm  water.  It  generallv 
quickly  ceases,  rarely  continuing  beyond  the  withdrawal  of  the  specu- 
lum. The  sitting  can  be  rept^ated  from  once  to  twice  each  week, 
and  may  be  extended  over  a  period  of  several  weeks  or  months,  the 
indication  being  to  continue  until  the  cervix  will  no  longer  bleed  freelv. 
This   little   operation   creates  but   slight  pain,   and    may   l)e    j)i-aetised 


614       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

without  the  patient  being  acquainted  with  its  nature,  and  at  the  physi- 
cian's office. 

Depletion  from  the  interior  of  the  cervical  canal  is  best  accomplished 
by  scarification,  done  by  a  long,  very  narrow-bladed  knife  (Fig.  199), 

Fig.  199. 


CTZTSESi'^ 


Knife  for  Intra-uterine  Scarilicatiou. 


which  on  insertion  to  below  the  os  internum  is  thrust  into  the  mucous 
membrane  to  sufficient  depth  to  sever  the  superficial  blood-vessels,  the 
incisions  being  extended  downward  over  the  rim  of  the  os  externum. 
The  number  of  scarifications  will  vary  from  two  to  six.  Both  punc- 
turing of  the  vaginal  face  of  the  cervix  and  scarification  of  the  cervical 
canal  may  be  done  at  the  same  sitting,  the  patient  being  directed  to 
remain  quiet  for  at  least  twenty-four  hours. 

Cupping  increases  the  flow  of  blood  after  puncturing,  but  it  is  ques- 
tionable whether  the  suction  efPect  of  this  method  does  not  draw  blood 
from  above  into  the  uterus.  The  same  objection  ma}^  be  urged  against 
leeching. 

As  to  the  value  of  local  depletion  of  the  uterus,  opinions  are  much 
divided.  A  decade  ago  it  was  much  in  vogue,  now  it  has  largely  gone 
out  of  use.  A  great  amount  of  this  change  in  the  methods  of  practice 
is  due  to  the  fashion  of  the  abandonment  of  local  bloodletting  in  all 
departments  of  medicine  and  surgery.  It  is  still  held  in  high  repute, 
however,  by  Freuch  gynecologists.  That  local  abstraction  of  blood  accom- 
plishes more  than  a  mere  temporary  clisengorgement  of  the  loaded  blood- 
vessels must  be  evident  to  any  one  who  will  judiciously  and  systemat- 
ically follow  the  practice.  The  changed  color  for  the  better  of  the 
uterus,  the  diminution  in  its  size  and  tenderness,  the  healing  of  ero- 
sions, the  decrease  in  the  discharge,  the  improvement  in  the  local  pain 
and  reflex  disturbances,  in  the  quantity  and  duration  of  the  menstrual 
disorders, — are  the  best  evidences  of  its  usefulness.  Each  abstraction 
of  blood  relieves  distension  by  partially  emptying  the  vessels.  For  a 
time  the  tone  of  the  vessels  is  improved  and  the  current  within  stim- 
ulated. A  repetition  of  the  practice,  aided  by  other  means,  gradually 
enables  the  vessels  to  more  permanently  contract  and  recover  them- 
selves. Scarification  not  only  empties  the  vessels,  but  a  division  of 
their  walls  with  the  knife  is  the  application  of  an  irritant,  provoking 
contraction. 

Another  advantage  of  puncturing  and  scarification,  besides  the  with- 
drawal of  blood,  is  the  rupturing  and  emptying  of  the  numerous  dis- 
tended muciparous  follicles  studding  the  surface  of  the  hyperplastic 
cervix,   extending  within  the  canal  and  imbedded   within   its  walls. 


ciiiiosic  Mii'inris,  irrc.  of  tiii:  rri'iius.  oi") 

Ovsti(^  (l(><;('iu'r:iti(>ii  is  a  coiistaiil  xiiiicr  of  irritation,  iiiaiiitainiiij^ 
livjH'rjpmia.  I'lincdiriiiLi dl  tli<>c  ictciit  inn-cysts  rapidlv  r<'licv»~  t<n- 
sion  ami  reduces  cerxiea!  cnLinruciiicnl.  Its  lli(»i'(iiit;li  and  i'c|(catcd 
a|)|>li("iti(>n  is  liic  ui(i>t  inijxirtant  incans  in  the  cniirc  dotrnclinn  nl' 
their  walls. 

I  jiical  i)l(iiidlelt  in^s  arc  I  lici'd'ore  cxtrcincK'  \aliia  Me  adjuncts  in  treat- 
ment. Indeed,  tlie\'  nia\'  lie  tlie  keystone  t(»  the  whole  htcal  nianaiic- 
iiu'iit.  \\\\\  tlicN  are  not  e(|nally  well  adapted  to  every  case.  Tiie.se 
features  of"  inipi-ovcnient  (so  I'ai'  as  the  lociil  abstraetion  of  blo(xl  is 
<'()iieeriu>d)  can  he  obtained  only  in  tiie  early  history  of  the  disease. 
When  inthn-ation  from  hyj)er|)lasti('  inliltration  lia.s  comnieneed  loeal 
depletion   is  useless. 

The  eontraindieations  to  ])nnetiirin<:;  and  .searifieation  are  few.  Tliese 
are — tendtwicies  to  profuse  hemorrliage  from  conditions  of  hrcinophilia ; 
great  varicosity  of  the  parts;  pregnancy;  and  finally,  subacute  and 
chronic  j)erimetritie  inflammation. 

3.  Medicinal  AppUcations. — Among  these  glycerin  ranks  first.  Pure 
anhydrous  glycerin — a  most  active  depletory  agent  on  account  of  its 
.strong  affinity  for  the  watery  elements  of  the  blood  of  the  congested 
vessels — should  always  be  selected.  If  there  is  coexistent  cervical  endo 
metritis,  with  erosion,  etc.,  the  glycerin  may  be  medicated  with  boric 
acid,  tannin,  etc.  Such  applications  ought  to  be  made  every  two  to 
three  days  on  absorbent  cotton,  so  packed  against  and  around  the  cer- 
vix as  to  freely  drain  it  and  to  give  support  to  the  uterus  if  there  is 
any  displacement. 

The  persistent  application  of  tampons  wet  with  the  glycerite  of 
alum  is  most  conspicuous  for  good  in  conditions  of  long-continued 
chronic  congestion  with  or  without  displacement. 

Iodine,  in  the  comjiound  tincture  or  a  stronger  tincture^  is  a  most 
valuable  alterative  and  stimulant  applied  to  a  congested,  hyperplastic, 
and  enlarged  uterus.  It  will  not  take  the  place  of  direct  depletion  by 
the  local  abstraction  of  blood  or  of  the  tamponade  with  glycerin.  Its 
special  field  of  utility  is  after  their  use  has  ceased  to  be  beneficial. 
Applications  of  the  mild  tincture  may  be  made  twice  weekly ;  of  the 
stronger  tincture,  about  once  weekly ;  carried  to  within  the  canal  if 
there  is  cervical  catarrh,  painted  over  the  whole  vaginal  vault  if  there 
are  remaining  indurations  of  old  cellulitis  or  peritonitis,  ])ut  always 
made  to  cover  the  whole  infravaginal  cervix. 

Observation  must  have  convinced  most  practitioners  that  chronic 
metritis  associated  with  erosion  and  granular  degeneration  is  not  unfre- 
quently  more  amenable  to  local  treatment  than  where  no  such  compli- 
cations exist.  The  recognition  of  this  fact  has  led  some  to  make  use 
of  local  irritants  to  produce  similar  conditions  when  they  were  not 
present.      The  effects  of   counter-irritation  have  been   held   in    view. 


616        THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

Applications  of  a  strong  acetic  vesicating  collodion  can  be  utilized  for 
this  purpose.  The  cervix  having  been  engaged  in  a  large  cylindrical 
speculum,  then  dried  with  pledgets  of  absorbent  cotton,  is  painted  with 
this  solution.  The  mucous  membrane  is  thoroughly  blistered ;  there  is 
a  free  discharge  of  serum,  perhaps  pus,  wdiich  flow  clej^letes  from  the 
tissue  above,  also  acts  as  a  revulsive  in  the  relief  of  pain  and  tender- 
ness, as  a  blister  does  to  an  inflamed  joint.  Similar  applications  may 
be  repeated  from  time  to  time  according  to  the  rapidity  of  the  healing 
process  and  the  effects  obtained. 

Upon  the  same  principle  much  more  active  agents,  the  strongest 
caustics — acid  nitrate  of  mercury,  chloride  of  zinc,  and  caustic  potash, 
the  actual  and  thermo-cautery — have  been  brought  into  use.  Setons 
through  the  cervix  also  have  been  employed.  Fortunately,  local  treat- 
ment so  severe  is  seldom  indeed  required.  All  possible  therapeutic 
effects  can  be  secured  without  these  painful  means  and  methods,  and 
their  use  too  often  indicates  mistaken  notions  of  the  pathology  of  the 
disease. 

Medicinal  injections  of  solutions  of  iodine,  potassic  iodide,  ergotin, 
have  been  carried  within  the  parenchyma  of  the  cervix  for  subinvolu- 
tion, chronic  metritis,  and  other  diseases.  The  results  obtained  at 
different  times  have  for  the  most  part  not  been  satisfactory  or  devoid 
of  danger.  There  is  a  possible  future,  however,  for  these  parenchy- 
matous injections  in  cervical  cancer. 

The  use  of  sponge  tents  under  proper  circumstances — where  the 
movements  of  patients  can  be  controlled — to  reduce  the  size  of  an 
enlarged  uterus  has  been  found  to  be  attended  with  excellent  success. 
Emmet,  with  whom  the  practice  is  original,  speaks  in  the  most  satis- 
factory terms  of  them  as  exerting  by  pressure  an  alterative  effect  on 
the  mucous  membrane  and  indurated  tissue,  exciting  the  whole  organ 
to  contraction,  and  depleting  from  the  circulation  by  the  profuse  watery 
discharge  provoked. 

Uterine  massage  was  introduced  into  gynecological  practice  by 
Brandt  of  Sweden.  Dr.  A.  Reeves  Jackson  of  Chicago  read  an 
excellent  paper  on  the  subject  before  the  American  Gynecological 
Society  in  1880,  stating  that  he  had  obtained  good  results  in  three 
cases  of  subinvolution,  areolar  hyperplasia,  with  parametritic  tender- 
ness and  fixation,  after  several  months  of  treatment.  Possibly,  the 
method  of  treatment  has  a  limited  field  of  utility  in  a  few  cases  of  the 
above-mentioned  diseases,  but  better  results  are  obtainable  by  other 
methods  less  tedious  and  much  less  objectionable. 

The  question  frequently  arises  in  practice  as  to  the  advisability  of 
the  adjustment  of  a  pessary  in  chronic  metritis  with  an  associated  dis- 
placement. When  tenderness  has  been  diminished  and  local  interfer- 
ence of  an  active  kind  is  no  longer  required,  the  proper  adjustment  of 


CiiiioMc  Mi:Ti:rri.\  irrr.  of  riir:  fn:i:us.  r,n 

a  wcll-fittiiii;'  |>('ss:iry  witli  a  bioad  l):ir,  hy  sii|)|Hti'tiii^- tlic  uterus  at  a 
proper  level  and  axis,  will  Taeilitale  the  i-etiini  of  llie  Mood  hy  the  veins, 
relieve  tension  ot"  the  Ineal  eirenlation,  and  piil  a  Inwdcd  oipm  ;it  rest. 
IC  the  displaeenieiit  perpetnates  a  disordered  eireidation,  it  is  eertainlv 
rational  to  eounleraet  it,  although  it  is  seeondarv  to  nietrilie  elian;i'es. 
The  applieatii>ii  of  an  ahdoniinal  l>andai;'e  has  likewise  its  j)lae<'  in 
certain   eases. 

Ampntatioii  of  the  <'ei'\i\,  when  greatly  hypertrophieil  IVoni  chronic 
ii\"|)erplasia,  has  lVc(|nentl\'  l)een  |)erfornied.  Since  the  da\.>  of  trach- 
oloplastv  and  the  rt'('OL;nilion  of  lacerations  of"  the  cervix  and  their 
results,  the  field  for  ainpntatiou  has  justly  been  <^rcutly  narrowed.  The 
g;reatest  liypertrophy  may  seemingly  be  present,  when  an  apposition  of 
the  everted  cervical  lips  will  dispel  the  delusion.  Pro[)er  repair  and 
restoration  of  the  cervix  to  position  by  Emmet's  operation  will  lead 
to  an  effiicement  of  the  enlargement  of  the  cervix,  and  with  it  to  a 
structural   improvement  in  the  whole  uterus. 

Still,  the  question  remains  open :  Is  amputation  ever  desirable  for 
conditions  resulting  from  chronic  metritis  other  than  lacerations  ?  The 
answer,  it  seems  to  the  author,  should  be  made  in  the  affirmative. 
Removal  of  portions  of  the  infravaginal  cervix,  it  is  wx'll  known, 
exercises  a  most  -wholesome  influence,  like  nnto  the  involution  process  on 
the  tissues  of  the  uterus  above.  The  effect  is  similar  to  that  noticca])le 
in  the  tonsils  after  a  superficial  section  has  been  removed.  Atrophic 
changes  follow'.  The  experiences  of  several  German  gynecologists,  Mar- 
tin, Schroeder,  Kehrer,  and  Olshausen,  also  of  American  authorities, 
Goodell,  Noeggerath,  Thomas,  and  many  others,  are  favorable  to  it. 
The  methods  of  amputation  after  Hegar,  with  circular  exsection,  the 
vaginal  mucous  membrane  being  stitched  to  the  cervical,  or  that  of 
Simon  and  Marckward,  of  flap  amputation  by  w'edge-shaped  exsection 
of  the  lips  separately,  the  divided  parts  being  stitched  together,  deserve 
following.  Some,  however,  prefer  to  leave  the  surface  unstitched,  to 
heal  slowly  through  suppuration  by  granulations,  believing  that  the 
secondary  changes  are  better  secured  thereby.  The  class  of  cases 
suitable  to  these  methods  is  those  with  enormous,  intractable,  other- 
wise incurable,  cystic  degeneration  and  great  longitudinal  hypertrophy, 
especially  of  the  supravaginal  portions  of  the  cervix. 

In  conclusion,  the  practitioner  is  ever  to  be  on  the  alert  in  searching 
for  and  treating  complications  Avhich  exist  or  may  arise.  Some  of 
these,  as  laceration  of  the  cervix  and  displacements,  may  have  been 
prime  factors  in  the  induction  of  the  disease ;  others,  as  fungosities 
of  the  endometrium,  cystic  and  granular  degeneration  of  the  cervix, 
vaginitis,  etc.,  are  more  often  secondary.  Anv  one  of  either  class 
will  aggra.vate  and  perpetuate  the  main  affection.  The  relief  of 
chronic  metritis  with    bad   cervical   laceration    is    improbable,    if   not 


618       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

impossible,  save  by  tracheloplasty.  Chronic  hypersemia  may  be  con- 
tinued indefinitely,  so  long  as  there  is  version  or  flexion  which  needs 
rectification.  Fungosities  of  the  uterine  cavity  provoke  and  repeat 
menstrual  disturbances,  thus  becoming  a  local  irritation  to  constantly 
invite  vascular  turgescence.  Cystic  degenerations  keep  the  cervix 
enlarged,  tender,  and  the  seat  of  profuse  discharges.  Vaginitis  is 
the  source  of  an  ever-present  discomfort. 

Eemove  the  complications  and  the  metritic  congestion  and  hyper- 
plasia are  placed  in  a  most  favorable  condition  for  amelioration  if  not 
cure. 

When  the  third  stage  of  the  disease— sclerosis  and  atrophy — has 
been  reached,  local  treatment  is  useless  except  for  the  complications: 
The  uterus  is  hopelessly  indurated  and  contracted.  Very  little  can  be 
done  for  an  increase  or  a  return  of  the  menstrual  flux.  Attention  to 
the  general  health  is  now  the  chief  employment  of  the  physician.  The 
local  use  of  electricity,  especially  intra-uterine  galvanization,  may  possi- 
bly be  of  service. 

Bibliography. 

Barnes  :  Diseases  of  Women. 

BoERNEE :    Ueber  den  Piierperalen  Uterus,  Gray,  1875. 

CouRTY  :  3Mad.  de  /'  Uterus,  1883. 

Emmet  :  Principles  and  Practice  of  Gynecology. 

Garrigues:  "Eest  after  Delivery,"  Amer.  Journal  Obstetrics,  vol.  xiii.  p.  845. 

Hart  and  Barbour  :  Manual  of  Gyncecology. 

Heschl:  Zeitschrift  der  Wiener  Aerzte,  vol.  viii.,  1862. 

Hodge  :  Diseases  of  Women. 

Jacobi,  Mary  P. :  "  Chronic  Metritis,"  Am.  Journ.  Obstet.,  vol.  xviii.  p.  802. 

Jackson  :  "  Uterine  Massage  in  Treatment  of  Certain  Forms  of  Uterine  Enlarge- 
ment," Transac.  Am,.  Oynecolog.  Soc,  vol.  v.  p.  80. 

Kehrer  :  "Transac.  German  Gynecolog.  Soc,"  Amer.  Journal  Obstet.,  vol.  xii.  p.  189. 

Klob  :  Pathological  Anatomy  of  the  Female  Sexual  Organs. 

Martin  :  "  Transac.  German  Gynecolog.  Soc,"  Amer.  Journal  Obstetrics,  vol  xii.  p. 
188. 

Munde,  Paul  F.  :  Minor  Surgical  Gynecology,  1885. 

Noeggerath  :  "Chronic  Metritis  in  Relation  to  Malignant  Disease  of  Uterus," 
American  Journal  Obstetrics,  vol.  ii.  pp.  505-610. 

ScANZONi :  Diseases  of  Females. 

ScHROEDER :  Diseases  of  the  Female  Sexual  Organs. 

Schucking:  Bulletin  general  de  Therapeutique,  Oct.  30,  1883. 

Simpson  :  Diseases  of  Women. 

Sinclair  :  "  Measurements  of  the  Uterine  Cavity  in  Childbed,"  Transac.  Amer.  Gyne- 
colog. Soc,  vol.  iv.  p.  231 ;   vol.  vi..  p.  325. 

Spiegelberg  :  "  Diagnosis  of  the  Early  Stages  of  Carcinoma  Uteri,"  ArchivfUr  Gyna- 
kologie,  vol.  iii.  S.  2,  1872. 

Thomas  :  Diseases  of  Women. 

Van  de  Wabker:  "Use  of  the  Seton  in  Chronic  Afiections  of  the  Womb,"  Amer- 
ican Journal  Obstet.,  vol.  v.  p.  226. 


cirnoMc  Mi:ri:iris,  iirc.  of  riii-:  r runes.  (iiit 

C^ONKTITITIONAI.      TlMOA  TM  HNT     nl"     (lIlJOMC    UtKUINK     InFI.AM- 

MATFoxs. — 'V\\v  coii-titiitloiuil  Ircatiiiciit  of"  clirdnic  ciKloiiiotritis  and 
nu'tritis  in  their  (lilVciciit  litniis  admits  of"  hut  little  \  ariatioii,  and  its 
cojisidcration   has  therefore   until    now   heeii    |)iir|)osely   postjxtned. 

A  <i;ejieral  siirvcn'  of  tlie  siil)jeet  l)i'ii)i;s  lis  to  consider  the  e.-peeial 
ada|)tal)ijit\'  of  local  and  p'neral  ti'catnicnt  to  each  individual  case. 
Kaeh  case  must  be  studied  by  itself.  Individual  teniperanioiits,  idio- 
syncrasii's,  constitutional  conditions  and  coinj)licati(jns,  the  amount  and 
kind  of  local  disease,  the  de<2:ree  of  tolerance  of  local  interference,  etc., 
must  receive  attention. 

A  local  disease  which  is  but  a  htcal  manifestation  of  a  constitutional 
state  especially  re(|iiires  constitutional  treatment.  Local  diseases  of 
purely  local  origin,  as  trauma,  when  of  short  duration  and  in  good 
constitutions,  need  no  constitutional  treatment.  Since,  however,  most 
c^ses  which  come  under  observation  are  suttering  not  only  from  a  local 
disea-se,  but  also  from  depreciated  general  health — faulty  nutrition,  be- 
sides reflex  disorders  manifested  in  a  multitude  of  symptoms — there  is 
a  call  for  both  local  and  constitutional  treatment.  The  reciprocal  rela- 
tions between  constitutional  conditions  and  local  lesions  are  intimate, 
never  ceasing,  and  cannot  be  disregarded.  In  fine,  in  a  majority  of 
cases  encountered  both  plans  of  treatment  are  essential,  a  neglect  of 
either  being  a  fruitful  source  of  failure. 

As  no  absolute  rule  is  apjilicable  to  all,  a  comparison  of  the  relative 
values  of  constitutional  and  local  treatment  in  chronic  uterine  diseases 
cannot  fairly  be  made. 

The  first  point  to  be  gained  in  general  management  is,  so  far  as  pos- 
sible, to  remove  the  cause  or  causes  producing  or  aggravating  the  local 
disease.  Among  these  may  be  enumerated  unnatural  and  unhealthful 
modes  of  life,  as  close  confinement  within-doors,  want  of  proper  exer- 
cise, faulty  habits  of  dress,  imperfect  and  insufficient  food,  prolonged 
lactation,  and  sexual  excesses.  It  is  generally  easy  to  remove  or  mod- 
ify these  evils,  provided  sufficient  interest  on  the  part  of  the  patient  is 
enlisted.  Numerous  cases  Ijy  way  of  illustration  in  the  jiractice  of  most 
physicians  can  be  called  to  mind.  Witness,  for  instance,  the  rapid  improve- 
ment from  a  course  of  treatment  in  some  patients  who  at  the  same  time 
live  ahfique  marito ;  the  marked  response  to  medication  after  weaning, 
following  prolonged  and  excessive  lactation  ;  the  quick  i-eturn  of  color, 
weight,  and  strength  after  a  change  of  diet,  air,  and  exercise  ;  the  relief 
of  pain,  the  abatement  of  leucorrhoea,  by  Avell-tiraed  and  judicious  rest. 

The  general  plan  of  management  consists  in  the  use  of  such  means 
and  measures,  hygienic,  medical,  mental,  and  moral,  as  tend  to  remove 
disturbances  of  function,  imj^rove  nutrition,  and  elevate  the  standard 
of  the  general  health. 

Rest. — AVith  the  body  in  the  recumbent  or  horizontal  j)osition  venous 


620       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

distension  of  the  pelvic  organs  is  lessened  and  congestion  is  diminished. 
Rest,  then,  is  beneficial  in  hyperseniic  conditions  of  the  uterus,  and  its 
advantages  should  always  be  made  available,  When  there  is  much 
local  tenderness  and  motions  of  the  body  are  attended  with  pain,  rest 
is  doubly  indicated.  The  presence  of  uterine  hemorrhage  and  the 
menstrual  period  are  also  indications  for  rest.  Prolonged  rest  in  the 
recumbent  posture,  on  account  of  the  close  confinement,  the  want  of  mus- 
cular exertion,  the  sluggish  circulation,  and  the  general  enfeebling  of  the 
whole  body  which  it  entails,  is  ever,  if  possible,  to  be  avoided.  It  is  sel- 
dom, indeed,  called  for,  except  in  perimetritic  complications,  and  then 
only  so  long  as  exercise  is  painful.  Prolonged  confinement  in  its  mental 
and  moral  aspects  is  ecpially  prejudicial  to  the  welfare  of  many  patients 
by  conducing  to  feelings  of  ennui,  helplessness,  irritabilit}'  of  temper,  and 
melancholy.  Its  whole  tendency  is  tow^ard  introspection,  with  a  multi- 
plication and  exaggeration  of  symptoms  purely  subjective  in  character. 

To  every  nervous  impression  such  patients  become  unduly  sensitive, 
and  when,  after  long  rest,  the  upright  posture  is  assumed  the  quick  dis- 
tension of  the  much-weakened  vessels,  through  gravitation  of  the  col- 
umn of  blood,  produces  a  degree  of  actual  suffering  in  itself  discour- 
aging to  many. 

As  Emmet  well  remarks,  there  never  was  a  greater  fallacy  in  prac- 
tice than  to  place  in  bed  a  woman  suffering  with  chronic  uterine"  dis- 
ease, under  the  expectation  that  she  will  recover  by  remaining  there. 
While  all  the  benefits  of  rest  may  constantly  be  taken  advantage  of  by 
directing  the  patient  to  lie  down  for  an  hour  or  two  each  day,  and  to 
observe  the  same  with  more  vigilance  at  the  menstrual  epochs,  all  of  its 
disadvantages  may  be  avoided  by  the  observance  of  proj)er  exercise. 

Exercise. — Exercise  promotes  cutaneous  exhalations,  increases  per- 
ipheral circulation,  and  equalizes  the  same,  so  often  distiu'bed  by  local 
stasis  mthin  the  pelvic  viscera.  By  it  the  appetite  is  improved ;  the 
capacit}''  for  the  digestion  of  greater  quantities  of  food  increased ;  the 
bowels  are  made  more  active,  the  muscles  firmer ;  the  body- weight  is 
augmented ;  and  sleep  is  favored.  Therefore,  as  a  rule,  as  much  exercise 
in  the  open  air,  and  in  cold  weather  within  the  direct  rays  of  the  sun, 
should  be  taken  as  the  strength  and  comfort  of  the  patient  will  permit. 
Exercise  which  creates  pain,  especially  if  persistent,  should  be  discon- 
tinued, but  that  which  is  followed  by  fatigue  only,  and  which  after  a 
few  hours'  or  a  night's  rest  passes  away,  is  to  be  encouraged.  Of  all 
the  different  methods  of  exercise,  none  is  superior  to  walking,  inasmuch 
as  it  secures  the  aforesaid  results  to  the  greatest  degree.  Attention  to 
the  manifold  duties  of  domestic  life  give  an  occupation  to  both  mind 
and  body  in  many  ways  most  desiral^le.  The  reaction  on,  and  the 
dej^letion  of,  the  general  health  from  local  pelvic  diseases  among  women 
in  the  middle  and  lower  ranks  of  life,  cceteris  paribus,  are  usually  less, 


cnnoMc  MF/rnrns,  rn:  or  riii:  rrnncs.  r,-2\ 

Ix'caiisc  of  a  <ii-cat('r  Kodily  activity  aimniji-  tlirm.  Tlic  piirsiiil  of"  |>lca>- 
iirc  and  travelling:  may  atlnrd  most  excellent  oppoi-tnnities  t"or  tlie  ohscrv- 
aiiccol  a  necessary  j»liysi<al  exercise.  I'^or  manifest  reasons  c'arriM<;e-i'i(l- 
in<;-  slionkl  not  supersede  walUin;::,  and  oiiulit  to  he  indnlticd  in  to  the 
exclusion  (tf  the  latter  only  hy  leehle  jjersons.  Florxltack  exercise  is 
to  l)e  interdicted.  Oalisthenic  exerci.ses  are  often  very  vahial)]c.  The 
patient  >liould  he  inihueil  with  the  idea  that  exercise  is  essential  to 
health,  and  that,  while  it  is  pussihle  to  take  hut  the  smallest  amount  at 
first,  it  is  to  he  «iiadually,  day  after  day,  increased;  then,  from  a  sen.se 
of  dutv,  hetween  proper  periods  of  repose  it  is  to  he  maintained  in  a 
free,  reuular,  and  systematic  manner. 

lidfhiiif/. —  In  the  (li.sca.scs  under  consideration  the  action  of  the 
cutaneous  surfaces  is  livnondly  defective;  exhalations  are  often  hinder- 
ed and  the  peripheral  circulation  is  inactive.  A  healthy  action  of  the 
skin  should  he  .secured  and  maintainetk  This  can  be.st  be  obtained  by 
aj)propriate  hathiuii',  friction,  and  exposure  of  the  .surface  of  the  body 
to  the  light  and  the  direct  rays  of  the  sun. 

Batliing:  once  or  twice  a  week,  simply  for  purposes  of  cleanliness,  is 
iLsually  insufficient.  More  frequent  bathing  (once  daily),  especially  in 
warm  weather,  may  be  ucce.s.sary.  Warm  and  hot  baths  best  augment 
the  exhalative  proces.ses.  Persons  with  weakly  constitutions  and  feeble 
reactive  powers  are  bettered  by  warm  or  tepid  baths.  The  Turkish 
bath  is  most  admirably  adapted  to  those  with  torpid  skins,  cold  extrem- 
ities, and  to  rheumatic,  gouty,  and  syphilitic  constitutions. 

Various  mineral  springs  which  possess  thermal  and  medicinal  quali- 
ties atibrd  bathing  properties  frequently  beneficial. 

The  cold  bath  (sponge  or  .shower)  is  more  tonic  and  exhilarant,  and 
is  suitable  to  the  more  vigorous.  The  addition  of  sea-salt  to  the  water 
assists  materially  the  remedial  effects.  Surf-bathing  often  proves  to  be 
mo.st  excellently  tonic. 

AVliatever  temjierature  or  method  of  bathing  is  practised,  there  should 
follow  immediately  the  most  vigorous  friction  with  coarse  towelling  over 
the  whole  surface  of  the  body.  The  immediate  effects  may  be  some- 
what fatiguing,  but  there  ensues  a  rapid  fluxion  of  blood  to  the  per- 
iphery, and  Avith  it  a  degree  of  warmth  of  the  body.  The  pelvic  vi.s- 
cera  are  relieved,  the  appetite  is  sharpened,  and  all  the  recon.structive 
processes  arc  quickened. 

Light  and  sunshine  arc  of  almost  equal  value.  The  human  system 
can  no  more  thrive  without  these  than  can  plants.  The  practice  of 
taking  sun-baths  under  ])roper  precautions,  to  those  who  possess  fit 
accommodations,  is  a  good  one. 

Clothing. — The  clothing  should  be  liglit.  easy,  comfortable,  and  withal 
sufficient  to  protect  the  body  during  all  .-reasons.  The  climate  through- 
out much  of  the  United  States  is  cxceediuiilv  trvinsx  to  manv  of  feeble 


622       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

health.  The  extremes  of  temperature  are  encountered  and  the  changes 
are  sudden  and  great.  Underwear  of  flannel  or  other  woollen  material, 
or  silk,  covering  the  entire  chest  to  the  neck  and  the  abdomen  and  the 
arms,  is  needed  during  the  greater  portions  of  the  year  in  this  latitude, 
and  can  be  graded  in  weight  according  to  the  season.  The  corset,  a 
source  of  so  much  injury  to  women  by  impeding  the  thoracic  move- 
ments, weakening  the  imprisoned  muscles,  depressing  the  diaphragm, 
and  through  it  the  abdominal  and  pelvic  viscera,  thereby  deranging 
their  circulation,  ought  to  be  proscribed.  To  avoid,  further,  any 
depression  of  the  pelvic  organs  all  clothing  ordinarily  suspended 
around  the  waist  should  be  supported  in  its  entire  weight  (five  to  ten 
pounds)  from  the  shoulders.  The  burden  of  extra  skirts  can  easily  be 
obviated  by  adopting  thicker  undenvear.  Cold  feet  and  extremities, 
the  source  of  pelvic  discomfort  and  dysmenorrhoea,  may  be  regulated 
by  friction,  exercise,  and  suitable  woollen  coverings. 

Air. — The  importance  of  open-air  exercise  and  the  exposure  of  the 
body  to  the  light  and  the  sun  has  already  been  suggested.  Byford 
recommends  a  plan  for  invalids  who  in  cold  weather  are  unable  to 
leave  their  rooms — viz.  dress  as  for  outdoors,  and  open  freely  all  the 
windows  and  doors  to  flood  the  room  with  fresh,  cool  air. 

Diet. — The  administration  of  food  is  one  of  the  most  essential  parts 
of  the  general  treatment — to  be  successful  requiring  intelligent  and 
faithful  care.  A  large  number  of  diseases,  especially  those  of  a  chronic 
tvpe,  proceed  from  errors  in  diet  as  to  the  quantity,  the  quality,  and  the 
time  of  partaking  of  food.  A  healthy,  vigorous  physical  constitution 
can  no  more  be  built  up  and  maintained  by  improper  and  insufficient 
food  than  a  steam-engine  can  be  run  on  a  defective  supply  of  fuel — an 
analogy  which  Pa\w  has  beautifully  illustrated.  The  effects  of  an  insuf- 
ficiency of  food  are  most  apparent  Y\-hen  the  deficiency  is  abrupt  and 
great — equally  manifest,  though  longer  developing,  when  the  quantity 
for  a  long  period  of  time  is  seemingly  not  much  below  the  average 
required  for  normal  nutrition.  Denutrition  may  be  a  speedy  or  a  very 
slow  process.  As  a  cause  in  the  production  of  chronic  diseases  it  is 
usually  in  the  latter  way.  Digestion  becomes  difficult  and  otherwise 
disordered  ;  there  is  constipation  ;  the  secretions  are  diminished.  The 
blood  is  lessened  in  quantity,  especially  the  red  corpuscles ;  the  watery 
element  is  increased ;  it  loses  its  plasticity,  and  a  tendency  to  hemorrhagic 
transudation  arises.  The  subcutaneous  fat  disappears ;  the  muscular 
tissues  lose  substance,  becoming  flabby ;  and  with  the  decline  in  the 
assimilative  process  there  is  a  fall  in  the  bodily  temperature.  Func- 
tional activity  in  all  the  organs  is  impaired,  the  nervous  system  being 
seriously  disordered. 

Graily  Hewitt  has  recently   communicated    some  interesting   factg 
showing  that  a  continued  insufficiency  of  food — a  chronic  starvation — 


ciuiosic  .y/rrnrns,  etc.  of  tuk  rr/:j:is.  ci^'', 

VJirviii<i'  i;i  decree,  lie  liad  tniiiid  aliiKtst  conslaiit ly  1(»  ('xi>(  in  the  cliidnic 
ilisi'Mscs  (iC  wnincii  cniiiinti'  hihIci"  liis  <il»s<'r\;iti<>ii.  'I'liis  (|ii:iiitil:ilivc 
(IfliciciicN'  had  cxlciidcd  dvcr  a  loii^  jJciMod  ol  (iiiif,  coiiinn'iiciM^  ;it 
jUilxTtv.  lie  di-aws  atlciilioii  (u  (lit-  indirect  cllccts  (it*  siidi  in^nllicicnl 
alimentation — meat  in  particnlar — in  |»r(Mlii('inn-  vascniar  di>(»r(l(i-s  dt" 
tlic  ntcrus,  clironic  catarrlis,  and  alterations  in  stnielnre  and  jto-ition. 
Clironie  ulcers  of  the  le^'  l)esj)eak  a  |>(»<»r  regimen,  and  will  not  heal  iC 
the  sn|)|)lv  of  food  is  dclective  in  (|nality  and  insnilieient  in  (jnantity. 
W'\\\  not,  also,  some  of  the  degenerations  of  the  cervix?  "Pain," 
says  Fothcruill,  "  is  hniiiicr  of  the  nerves  for  food."  ....  "Xenraljfia 
is  a  prayer  for  healthy  blood."  The  truth  of  these  facts  nnist  he  patent 
to  every  praetitionor.  Among-  no  class  or  race  of  \v(tnien  are  these 
deleterious  inHnenees  more  strikiuiilv  observed  than  in  the  American. 
AN'ith  foods  in  quantities  more  abundant  than  elsewhere  in  the  world, 
and  in  (|uality  inferior  to  none,  a  slow,  insidious  process  of  starvation 
from  false  notions  of  diet  has  become  a  most  potent  factor  in  the  cau- 
sation of  ])elvic  diseases  in  our  American  o;irls  and  women.  On  the 
other  hand,  a  oenerous  diet  improves  the  hsematosis,  increases  func- 
tional activity,  augments  the  body-weight  and  heat,  imparts  tone  and 
tirmncss  to  the  blood-vessels  and  tissues,  and  diminishes  the  sensibility 
of  the  nervous  system  to  pain  and  reflex  irritation.  A  good  diet  is 
su])erior  to  medicine  in   the  renewal  of  the  body. 

Tlie  diet  of  women  suffering  with  chronic  uterine  disease  should  be 
plain,  simple,  easy  of  digestion,  but  highly  nutritious  and  taken  at 
regular  intervals.  It  is  necessary,  therefore,  that  the  attendant  specify 
what  articles  of  food  are  to  be  eaten,  how  much,  and  at  what  intervals. 
No  inflexible  rules  can  be  laid  down  for  all  persons.  The  same  foods 
do  not  agree  equally  ^^■ith  every  one.  Personal  likes,  idiosyncrasy,  are 
to  be  consulted  and  in  a  measure  used  as  a  guide. 

Of  all  the  alimentary  principles — nitrogenous,  hydro-carbons,  and 
carbo-hydrates — the  first  is  the  most  valuable.  Animal  food  ranks 
very  high  among  the  elements  of  nutrition.  Meat,  especially  beef,  of  good 
quality  and  properly  cooked  (broiled  and  roasted),  is  ordinarily  as  easy 
of  digestion  as  are  fluid  foods,  and  for  a  constant  diet  is  easier.  Its  free 
use  improves  the  quality  of  the  blood,  increasing  the  number  of  red  cor- 
puscles, and,  as  Liebig  has  shown,  force  in  excess  is  developed.  Fat  is 
not  increased,  but  muscular  activity  is  promoted.  It  is  claimed  also 
that  such  diet  diminishes  the  risk  of  the  occurrence  of  phthisis,  which, 
if  true,  is  a  fact  of  the  greatest  importance  in  this  relation.  Meat  in 
some  form — beef,  lamb,  or  mutton,  game,  poultry,  oysters  and  fish — 
should  be  taken  freely,  and,  as  a  rule,  some  one  of  these  three  times  a 
day.  A  too  free  or  frequent  use  of  soups  is  to  be  avoided :  they  are 
adjuncts  to,  but  not  substitutes  for,  solid  foods.  ]\Iilk  and  eggs  are 
rich  in  nitrogenous  matter.     The  former  contains  a  considerable  quan- 


624       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

tity  of  fat ;  the  latter  possesses  a  maximum  of  nutrition  in  a  minimum 
of  bulk.  Their  use,  save  in  exceptional  cases  where  they  disagree,  is 
to  be  encouraged.  A  most  excellent  plan  of  dietary  in  cases  of  mal- 
nutrition embraces  the  ingestion  of  a  half  to  a  whole  pint  of  fresh,  pure 
milk  from  one  to  two  hours  after  meals :  if  digestion  is  feeble,  it  may 
be  taken  pejatonized.  A  cup  of  warm  or  hot  concentrated  beef-tea  or 
beef  peptonoids  in  solution  may  advantageously  be  substituted  once  a 
day  for  the  milk.  In  conditions  of  marked  feebleness  of  digestion  the 
diet  should  be  restricted  to  milk,  pure  or  peptonized,  and  beef  pep- 
tonoids, until  the  stomach  can  tolerate  solid  food. 

Foods  containing  much  starch  and  sugar — the  carbo-hydrates — stand 
lower  in  the  nutritive  rank  and  lowest  in  the  strength-giving  qualities. 
Partaken  of  too  freely  to  the  exclusion  of  nitrogenous  foods,  they  tend 
to  indigestion,  acidity,  and  flatulency.  They  have  their  j)lace  in  our 
dietary,  and  for  variety  are  needed.  The  cereals,  vegetables,  and  fruits 
belong  to  this  class.  Bread,  which  stands  first,  possesses  nutritive  prop- 
erties of  the  highest  order.  Wheaten  bread  should  be  prepared  from 
the  entire  grain.  Vegetables  may  be  taken  in  moderation,  not  more 
than  one  to  two  at  a  single  meal.  The  same  holds  true  in  reference  to 
fruits. 

The  fats — the  hydro-carbons — though  not  the  exclusive,  are  active 
fat-,  heat-,  and  strength-producing  agents.  Butter,  cream,  fats  of  meats, 
oils,  etc.,  articles  of  this  class,  are  most  valuable  elements  of  alimenta- 
tion when  there  is  malnutrition,  lack  of  adipose  tissue,  spansemia,  etc, 
— conditions  in  which  there  is  always  an  increased  susceptibility  to 
changes  of  temperature,  to  pain,  and  a  diminished  bodily  resistance  to 
disease,  Pavy  expresses  it  thus  :  "  Fat  accumulated  within  the  vesicles 
and  susceptible  of  reabsorption  into  the  blood  forms  a  store  of  force- 
producing  material  to  be  drawn  upon  as  circumstances  may  require," 
Consistent  with  the  ability  to  digest  foods  of  this  order,  their  use,  under 
proper  indications,  may  be  urged.  Cream  with  oatmeal,  abundance 
of  butter  upon  bread,  and  well-cooked  meat-fats  are  selections  which 
may  be  made  with  the  object  in  view. 

Coffee,  if  taken,  should  always  be  in  moderation,  not  to  exceed  once 
daily  (a,  m,).  On  account  of  its  tendency,  with  some  persons,  to 
derange  digestion,  and  being  a  most  active  stimulant,  it  will  be  found 
well  at  times  to  discontinue  it.  Tea  is  less  stimulant,  and  can  generally 
be  taken.     Cocoa  and  chocolate  make  excellent  substitutes. 

The  use  of  alcoholic  stimulants  demands  the  greatest  caution.  An 
invalid  woman  is  even  more  prone  than  the  sterner  sex  to  contract 
habits  of  excessive  alcoholic  drinking.  The  grateful  effects  quickly 
expressed,  the  free  relief  to  the  sensations  of  languor  and  nervousness, 
soon  pave  the  way  to  their  too-frequent  and  too-free  use.  Very  rarely 
ought  alcohol  to  be  prescribed  under  the  plea  of  depression  and  exhaus- 


ciinoMc  Mi:ri:i'ns,  j-rn:  of  riii:  rT/:i:rs.  r,-2') 

tioii.  Wine  or  limit  li<|ii<irs,  in  iiiodcratioii,  taken  with  the  more  licarty 
meal,  iniidiicc  to  »li;icstii»n,  arc  (|iiickly  assimilated,  and  in  sek-eted  eases 
Im'coiiu'  lieiiefieial.  To  tlntse  wlin  lalmr  nmler  li-eljle  diLre>ti<in,  are 
aiiiPinic,  and  of"  s|)are  lialiit,  and  w  lio  can  Ix-  trusted  with  their  ii-e,  the 
aroresaid  alcoholic  l)everai;cs  may  occasionally  he  prescrihcd. 

Certain  ai-ticles  of  diet,  as  pies,  cakes,  most  puddiiifrs,  nuts,  and 
candies,  should   he  interdicted. 

The  great  underlvin<;  principles  ol"  alimentation  are,  to  select  -neh 
foods  as  do  not  dcrantro  djtjestion,  but  improve  it  if  disordered,  ancl, 
ahove  all,  to  introduce  such  (|uantities  of  the  best  nutriments  as  the 
diji-estive  oro;ans  have  capacity  to  incorporate. 

The  ingestion  of  foods  at  proper  and  regular  intervals  is  of  the  next 
importance — a  rule  of  equal  value  where  there  is  anorexia.  It  will  not 
do  to  wait  for  an  appetite  ;  in  the  mean  time  the  })atient  may  be  starv- 
ing. As  is  light  to  the  eye,  so  is  food  the  natural  stimulant  to  the 
stomach.  A])petite  can  be  created  by  its  judicious  ingestion.  In  the 
foregoing  j)lan  and  choice  of  diet  the  patient  should  be  instructed  and 
held  until  habit  and  taste  are  created. 

Attention  to  Functions  of  Digestion. — In  addition  to  a  systematic  reg- 
ulation of  the  dietary  the  employment  of  certain  medicines  plays  a 
most  important  role  in  aiding  the  functions  of  digestion.  So  frequently 
are  these  functions  disordered  that  it  is  seldom  they  do  not  require 
some  special  attention,  which,  so  far  as  medication  is  concerned,  should 
be  the  first  step  in  general  treatment.  Appetite  is  to  be  promoted  and 
the  various  symptomatic  disorders  of  the  stomach  are  to  be  controlled. 
For  the  first,  such  stomachics  as  the  vegetable  bitters — nux  vomica  in 
tincture  or  its  alkaloid  strychnine ;  cinchona  in  tincture  or  elixir,  or  its 
chief  alkaloid  quinine;  gentian,  quassia,  etc. — are  the  best.  These  act 
most  favorably  when  administered  before  meals,  and  besides  improving 
the  appetite  they  give  tone  to  the  stomach,  facilitating  primary  diges- 
tion. To  further  aid  in  the  solution  of  the  food  the  artificial  digesters, 
]iepsin,  lacto-pcptin,  and  muriatic  acid,  may  be  prescribed  after  meals. 
They  are  chiefly  indicated  where  there  are  sensations  of  heaviness  and 
weight  after  eating,  attended  or  not  with  acidity  and  flatulency.  The 
mineral  acids,  muriatic  and  nitro-muriatic,  Avell  diluted,  frecjuently  con- 
trol acidity  and  flatulency  better  than  the  alkalies  and  more  permanently. 
In  derangements  of  the  secondary  functions — imperfect  digesti<»n  of 
the  albuminoids,  fats,  and  starches  from  some  defect  in  the  pancreatic 
secretions,  etc. — pancreatic  powder,  some  time  after  meals,  may  artifi- 
cially be  substituted.  Ipecacuanha  powder,  in  small  doses  (gr.  \-^) 
after  meals,  is  a  remedy  of  no  mean  power  in  this  direction,  stimulating 
the  flow  of  gastric  juice  and  bile. 

The  efficaciousness  of  most  of  these  remetlies  may  be  enhanced  by 
various  combinations.     Thus: 

Vol.  I.— 40 


626       THE  INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS. 

^.  Strychninse,  gr.  ss ; 

Acid,  nitro-muriat.  dilut.,  3ij  ; 
Aquse  destillatae,  sij.     S.  et  M. 

Sig.  Ten  drops,  with  water,  before  meals, 

]^.  Pepsinse  (Fairchild's),        Bj  ; 
Pulv.  ipecacuanhse,  grs.  v  ; 

Extract,  gentianse,  Bj.     ]\I. 

Ft.  in  pil.  XX. 
Sig.  One  pill  after  each  meal. 

^.  Pepsinse  (Fairchild's),        Bj  ; 
Quininse  sulphatis,  yij  ; 

Strychninse,  gr.  ss.     M. 

Ft.  in  pil.  XX. 
Sig.  One  pill  after  each  meal. 

The  addition  of  extract  pancreatis  (grs.  ij)  to  either  of  the  above 
formulae,  or  ext.  pancreatis  with  sodium  bicarbonate  (each  gr.  iij),  given 
alone  after  meals  when  this  remedy  is  indicated,  may  be  prescribed. 
The  peptonizing  of  food,  a  process  of  partial  digestion  before  stomach 
ingestion,  first  practically  suggested  by  Wm.  Roberts,  F.  R.  S.,  of 
London,  has  much  to  recommend  it.  While  its  field  of  utility,  par 
excellence,  is  intestinal  indigestion,  its  use  need  not  be  thus  limited. 
Many  cases  of  malnutrition  needing  full  feeding  have  feeble  digestion. 
The  artificial  digestion  of  milk  or  beef  so  prepared  is  a  great  assistance. 

For  the  symptoms  of  gastralgia  no  remedies  act  more  promptly  than 
bismuth  subnitrate  (grs.  x)  or  Fowler's  solution  (gtt.  j-ij)  before  meals. 

A  teacupful  of  hot  water  from  a  half  hour  to  an  hour  before  meals- 
has  been  found  to  be  an  excellent  means  to  improve  the  digestion  in 
many  cases  of  atonic  dyspepsia  and  chronic  gastric  catarrh.  The 
stomach  is  washed  of  adherent  mucus,  the  blood-supply  is  tempo- 
rarily increased,  the  secretion  of  gastric  glands  promoted,  and  the 
whole  functional  activity  of  the  digestive  organs  facilitated. 

The  malt  extracts,  rich  in  diastase,  assist  the  digestion  of  starchy 
foods,  besides  possessing  in  small  bulk  valuable  restorative  principles. 
They  may  be  taken  with  or  after  meals. 

Attention  to  the  Functions  of  the  Bon-els. — There  is  no  more  common 
complication  of  chronic  uterine  diseases  than  constipation,  none  more 
serious,  none  Avhich,  for  the  want  of  proper  attention  thereto,  is  more 
calculated  to  retard  a  progress  to  recovery.  Considering  the  frequency 
and  the  extent  to  which  constipation  exists  in  some  women,  it  is  no 
longer  a  matter  of  surprise  that  it  is  a  most  fertile  source  of  pelvic 
disease.  Not  only  does  constipation  impede  venous  flow  within  the 
rectum,  favoring  congestion  and  hemorrhoids,  but  it  directly  influences. 


CHRONIC  M/rriilTIS,   ETC.   OF  THE   UTERUS.  iVll 

In  till'  sMiiic  maiuK  r  the  \  rnoiis  ciiciilMtiuii  within  iho  uterus  and  remain- 
ini;-  |)cl\ic  vi>('<'i-:i.  The  uterus  is  not  nuly  pressed  upon  or  bent  out  of 
position  l»v  H'cal  accuuuilatious  witliiu  the  colon  and  reetuui,  hut  hy 
an  iucrrased  vaseidarity  it  is  rendered  heavier.  Its  lij^anientous  attach- 
ments are  stretched,  rehixed,  and  weaUeiied.  Here  are  two  lactors 
ahine  conducive  to  displaceinents.  Indirectly  coiniecte<l  with  the 
pelvic  eireiilation  is  the  portal,  which  in  turn  inn-t  he  made  slntr- 
gish.      Ap|)etite  and   di<j:estion   are   now    impaired. 

It  is  a  sul)ject  of"  wonder  wiiy  i)Iood-poisonin<i;;,  from  an  al)soi-j)tion 
of  the  decomposing  matter  of  large  accumulations  of  feces  long  retainetl, 
does  not  ofteiKM-  manifest  itself  The  aljsence  of  the  more  serious  symj)- 
toms,  which  might  attract  attention,  only  demonstrates  the  capacity  and 
endurance  of  the  human  sy.stem  even  under  adverse  circum.stances.  A 
slow,  insidious,  chronic  toxremia,  escaping  notice,  is  doubtless  sometimes 
present.  If  the  system  sutlers  from  bad  drainage  and  defective  sewer- 
age without,  why  not  within,  the  body?  Excrementitious  matter, 
long  retainetl,  must  decompose  and  foul  gases  be  generated ;  these, 
together  with  the  liquid  elements  of  the  feces  and  products  of  w'a.ste 
tissue,  become  absorbed,  vitiate  the  blood,  irritate  the  nervous  centres, 
and  derange  every  function. 

Free  alvine  evacuations  can  be  secured  daily  by  means  hygienic  and 
medicinal.  Among  the  first  are  exercise,  diet,  drink,  and  regular  habits. 
Bodily  exercise,  w^alking  in  particular,  conduces  to  intestinal  as  well  as 
other  muscular  vigor  and  streno-th.  The  sedentarv  habits  of  women 
fiirnish  one  of  the  principal  reasons  for  the  much  greater  frequency  of 
constipation  in  their  sex.  Foods  which  contain  a  certain  proportion 
of  refuse  material  stimulate  intestinal  peristaltic  action.  Such  foods 
are  cracked  wheat,  coarse  oatmeal,  corn  and  Graham  bread,  and  the  suc- 
culent vegetables,  fruits,  and  berries.  The  former  are  otherwise  exceed- 
ingly valuable  in  view  of  their  nutritive  properties ;  the  latter,  while 
less  nutritious,  afford,  on  account  of  their  different  acids,  a  much-neetled 
variety  and  promote  gastric  and  intestinal  secretions.  If  properly 
selected  as  to  time  of  eating,  quantity,  and  quality,  they  need  not 
interfere  witli  digestion.  Coffee,  and  particularly  green  tea,  in  excess 
constipates.  Water  freely  imbibed  on  an  emjity  stomach — above  all,  in 
the  morning  fasting — favors  intestinal  action  and  liquefies  the  fecal  accu- 
mulations. Its  virtues  are  materially  enhanced  by  the  addition  of  a 
modicum  of  common  table-salt.  Congress,  Hathorn,  Blue  Lick,  and 
various  sulpho-saline  waters  act  similarly,  are  most  effective,  but  should 
be  regarded  rather  in  the  light  of  medication  to  be  avoided  if  possible. 

Constipation  is  a  disease  the  cure  of  which  can  be  obtained  only  bv 
studying  individual  cases  and  causes.  ]Mental  attention  directed  to  the 
bowels  in  endeavoring  to  obtain  an  alvine  movement  at  regular,  stated 
times  is  a  matter  of  prime  importance.     Habit,  albeit  of  slow  develo])- 


628       THE  I^'FLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

ment,  can  be  established  in  this  regard  with  perfect  regularity,  failures 
largely  resulting  from  a  want  of  due  patience  and  perseverance.  A  visi- 
tation to  the  water-closet  at  a  certain  hour  (after  breakfast),  interrupted 
and  prevented  by  naught  else,  be  it  friends,  business,  indisposition,  or  the 
weather,  and  there  remaining  for  it  may  be  half  an  hour,  rarely  fails 
after  a  few  weeks  to  be  successful.  The  posture  should  be  easy,  and  no 
straining  allowed.  The  simple  concentration  of  the  mind  upon  the 
present  duty  has  its  influence  over  the  body.  As  a  well-constructed 
water-closet  is  one  of  the  most  important  parts  of  house-building,  it 
should  be  accessible,  convenient,  comfortable,  clean,  and  inviting. 
Goodell  has  drawn  attention  in  a  most  graphic  manner  to  the  baneful 
influences  of  the  old  water-closet  (privy)  system  in  causing  constipation. 

Every  effort  should  be  made  by  the  aforesaid  means  of  diet,  drinks, 
exercise,  and  regularity  of  habits,  to  obtain  free  and  regular  alvine  move- 
ments before  resorting  to  the  use  of  any  medication.  Medicine  is  quite 
generally  needed,  but  it  ought  always  be  borne  in  mind  that  it  gradu- 
ally loses  its  eifect,  and  that  the  more  taken  the  more  will  be  required. 
Drugs  stand  in  a  subordinate  rank  to  hygienic  measures.  The  various 
laxatives  and  cathartics  act  by  virtue  either  of  promoting  intestinal  secre- 
tions or  of  exciting  muscular  peristalsis.  Constipation  presents  condi- 
tions of  defective  secretion,  in  either  the  upper  or  the  lower  intestine,  or 
paresis  of  the  muscular  fibres  of  the  intestinal  tube.  Defective  secretion 
in  the  upper  intestine  is  evidenced  by  clay-colored,  pasty,  unhealthy- 
looking,  offensive  stools ;  in  the  lower  intestine,  by  hard,  dry,  scyba- 
lous formations.  Obstructions  to  the  alvine  passages  are  encountered 
within  the  pelvis  on  account  of  uterine  enlargement  and  displacements 
— notably  retroversion  and  flexion.  Thus,  the  various  indications  for 
the  use  of  the  different  remedies  are  obtained. 

Defective  secretion  of  the  upper  intestine  calls  for  such  remedies  as 
mercurials,  podophyllin,  euonymin,  leptandrin,  iridin,  ipecac,  aloes, 
and  rhubarb  ;  of  the  lower  intestines,  the  salines.  Muscular  inactivity 
of  the  intestines  is  met  by  nux  vomica,  belladonna,  physostigma,  aloes, 
'  and  faradization.  Two  or  more  of  these  indications — defective  secre- 
tion and  muscular  torpor — often  present  themselves.  The  practice 
adopted  by  Emmet  and  Byford,  of  commencing  the  treatment  of  those 
who  have  long  suffered  as  chronic  invalids  by  administering  the  mild 
chloride  of  mercury  as  a  cholagogue,  and  occasionally  repeating  the 
same  or  mercury  in  the  form  of  blue  pill,  folloAved  by  a  saline  as  a 
cathartic,  is  doubtless  very  efficient  in  stimulating  the  portal  circulation 
and  secretions,  dislodging  fecal  accumulations,  and  preparing  the  way  for 
stomachic  tonics.  These  remedies  have  also  a  I'evulsive  effect  on  the 
congested  pelvic  viscera.  This  plan,  although  seemingly  harsh,  is  not 
always  contraindicated  even  in  states  of  debility  and  anaemia. 

When  the  tongue  is  furred,  the  alvine  movements  small,  hard,  dry, 


vniiosic  Miyniiris,  etc  o/-  the  cteui's.  c>2'.) 

ami  paliiliil,  llu-  \;Minii>  miiw  r:il  \\atn>,  taktii  in  the  iiidiiiiii;;  lasting;, 
ait'  atla|)lf(|.  Tlit-  Idllowiiii;-  mixture  ol"  siilpliatt'  itl  iiia;j:ii<'sia  and  siil- 
plmric  aii<l  witli  sulphate  of  intn,  if  indicated,  answers  well  in  many 
eases,  lieinu"   Imtli    la\ali\c  ami    tunic: 

1^,    .Ma^nesiie  snipliatis,        .sj  ; 
Acidi  sidplnirici  dilnti,  ."j  ; 
Fcni  >nlpljatis  exsie.,     ^rs.  xvj  ; 
A(|ii:e  destillat.  ad  S^i'j-      ^I- 

iSiii-.   A  tal)le.-iH>onrnl  or  more  in  a  wineu-lass  ot'culd  water  before  break- 
flUst. 

Or  maiiiiesia  sid])liate  (SJ-oi.)),  dissolved  in  a  tiunblerfnl  <A'  water,  to 
be  taken  each  morning  before  breakfast,  gradnally  diminishing  the  qnan- 
tity  of  the  medicine  as  habit  is  created,  always,  however,  maintaining 
the  original  (piantity  of  the  water,  may  be  preseribetl.     Carlsbad  salts 
or  sodinm  phosphate  may  1x3  substitnted  for  the  magnesia  snlphate. 
The  following  forrauhie  will  be  fonnd  to  meet  many  indications : 
^i.   Resina?  podo])hvlli, 
Ext.  nueis  vomicoe, 
Ext.  belladonna,  del,  grs.  ij. 
M.  Ft.  in  pil.  xii. 
Sii;.  One  at  bedtime  if  no  movement  during  the  dav. 

R,   Aloein,  grs.  iv  ; 

Stryehnife,  gr.  ^  ; 

Ext.  belladonuse,    grs.  iij. 
M.  Ft.  in  pil.  xx. 
Sig.  One  at  bedtime  if  necessary. 

I^.  Resinse  podophylli,  grs.  iv  ; 

Pulv.  ipeeacuauhte,  grs.  iv  ; 
Ext.  eoloeynth.  comp.,    grs.  xxiv  ; 

Ext.  nncis  vomicae,  grs,  iv  ; 

Ext.  belladonnse,  grs.  iv. 
M.  Ft.  in  pil.  xxiv. 
Sig.  One  pill  at  bedtime. 

The  Rhamnus  Purshiana  (Cascara  sagrado),  in  the  form  of  the  fluid 
extract  (gtt.  x— xxx),  is  quite  usually  an  excellent  laxative. 

So  soon  as  the  proper  dose  of  any  laxative  medicine  has  been  deter- 
mined, and  the  bowels  by  its  aid  have  established  regularit}-  of  evacua- 
tion, the  dose  should  be  gradually  diraiuishe<l  until  none  is  taken. 

The  colon,  and  especially  the  rectum,  of  women,  after  years  of  con- 
stipation generally  have  become  greatly  dilated  and  have  lost  all  con- 
tracting power.  Instead  of  a  canal  for  the  passage  of  fecal  matter,  they 
are  transformed  into  an  immense  sac  for  its  accumvdation.  The  frefpient 
administration  of  active  resinoid  cathartics  onlv  increases  this  diffieultv 


630       THE  INFLAMMATORY  AFFECTIONS   OF  THE    UTERUS. 

by  leaving  the  parts  in  an  increasingly  weakened  state.  Manipulation 
of  the  abdominal  walls  by  kneading,  especial  attention  being  given  the 
whole  track  of  the  ascending,  transverse,  and  descending  colon,  may  be 
resorted  to  with  advantage.  Direct  faradization  of  the  abdomen  and 
intestines  (rectum  included)  may  be  useful.  Both  measures  require  to 
be  persevered  in  for  a  lengthened  period.  The  injection  of  cold  salt 
water  (about  half  a  pint)  within  the  rectum  will  not  only  empty  it,  but 
tends  to  excite  muscular  contraction.  But  the  frequent  and  long-con- 
tinued use  of  enemata  is  to  be  discouraged,  as  calculated  to  induce  the 
condition  referred  to.  The  author  has  seen  some  excellent  results  after 
perineorraphy  and  colporraphy  for  constipation  dependent  upon  relaxed 
vaffina  and  rectum. 

As  a  dernier  ressort  in  some  cases  paralyzation  of  the  sphincter  ani 
by  forcible  dilatation  may  be  tried. 

General  Medication. — The  whole  range  of  tonic  medication  becomes 
more  or  less  useful  in  the  treatment  of  the  chronic  uterine  diseases  with 
depreciations  of  the  general  health.  For  practical  purposes,  all  tonic 
and  restorative  measures  might  be  limited  to  the  following :  quinine^ 
nux  vomica,  iron,  arsenic,  phosphorus,  cod-liver  oil,  electricity,  and 
massage.     Each  of  these  deserves  special  mention. 

Quinine,  the  chief  alkaloid  of  cinchona,  is  the  best  representative  of 
the  whole  list  of  bitter  tonics.  In  moderate  doses  (grs.  j-iij,  ter  die)  it 
is  a  stomachic  tonic,  a  general  restorative  tonic,  promoting  constructive 
metamorphosis  and  increasing  mental  and  somatic  activity.  It  is  not  a 
special  uterine  stimulant,  but  indirectly  by  its  use  such  an  influence 
may  be  exerted.  These  well-known  effects  of  quinine  enable  the  phy- 
sician to  utilize  it  in  a  large  number  of  the  chronic  diseases  of  women. 

Nux  vomica,  besides  its  field  of  usefulness  in  the  atonic  and  nervous 
forms  of  dyspepsia  and  torpid  states  of  the  intestines,  is  employed  in 
small  doses  for  its  stimulo-tonic  effects,  through  the  vaso-motor  nerves 
and  centres  in  the  spinal  cord,  to  contract  the  arterioles  and  muscular 
fibres,  thereby  increasing  the  arterial  tension  and  improving  the  local 
circulation.  Quinine  and  iron  have  their  virtues  as  tonics  increased  by 
a  combination  with  nux  vomica  or  strychnia. 

Iron  is  probably  more  frequently  prescribed  for  the  chronic  diseases 
of  women  than  any  other  remedy,  and  no  other  is  capable  of  doing 
more  good  in  properly  selected  cases.  The  common  rules,  that  iron 
should  not  be  given  when  the  temperature  is  elevated,  the  pulse  fre- 
quent in  connection  with  increased  temperature,  the  tongue  furred  and 
foul,  the  liver  inactive,  and  the  urine  scanty  and  thick,  are  ever  to  be 
borne  in  mind.  Local  contraindications  are  equally  important.  Iron 
increases  pelvic  congestion  in  either  sex,  provokes  pain  when  the  uterus 
and  ovaries  are  actively  congested,  and  tends  to  excite  menorrhagia. 
Much  harm  is  often  actually  done  in  these  conditions  by  saturating 


riuioMc  Mi:iniTi.\  j-nv.  of  tiih  uterus.  g.U 

patients  with  the  preparations  of  iron.  Tlic  ili<;estive  iin<l  alimentary 
disorders  tii^st  need  correcting,  and  the  excretions  shoidd  he  made  free 
before  iion  can  |)roperly  he  assimihited.  The  general  indications  are — 
anaMiiia,  strnma,  syj)hilis,  and  some  nenroses  (neural<xia.<) ;  the  IfK-al — 
amenorrlKoa,  dysmenorrhea,  lencorrhwa,  torpid  and  flahhy  states  of"  the 
uterus,  espeeially  in  anjoiuie  subjects  and  the  ])hlegmatic  temperament. 

Quinia  and  strychnia  are  oflen  ])rescril)ed  together  as  a  tonic,  and 
when  there  is  no  oi))ection  t<)  iron  all  these  agents  may  be  combined,  as — 
K.    Puiv.  I'crri  redaeti,  grs.  xxx  ; 
Quiiiinie  sulphatis,  .^j  ; 
8trvchnina\  gi'- 1  j 

Ext.  gentianae,         q.  s. 
INI.  Ft.  in  pil.  xxx. 
Sig.  One  pill  after  each  meal. 

The  best  preparations  of  iron  are — iron  ]ier  hydrogen,  pill  of  the 
carbonate,  sulphate,  tincture  of  the  muriate,  syrup  of  the  iodide 
(Creuse's  formula),  and  the  pyrophosphate. 

Blaud's  pill  of  the  carbonate  of  iron  (grs.  ij-iij,  ter  die)  has  had  a 
deservedly  high  reputation  for  anaemic,  chlorotic,  and  amenorrhoeic 
females.  Xo  preparation  of  iron  is  so  efficacious  to  rapidly  furnish 
the  needed  material  to  the  blood  as  the  muriated  tincture.  In  those 
exceptionally  rare  cases  where  uterine  hemorrhage  is  prolonged  by 
extremely  watery  conditions  of  the  blood,  lacking  all  power  of  spon- 
taneous hiiemostasis,  this  preparation  of  iron  is  xery  serviceable. 
Creuse's  syrup  of  the  iodide  is  well  adapted  for  strumous,  s^'philitic, 
and  tubercular  cases.  A  light,  agreeable,  and  efficacious  preparation 
of  iron,  which  does  not  constipate  the  bowels,  is  the  pyrophosphate. 
The  following  is  a  favorite  formula  : 

R.  Ferri  pyrophosphatis,  3] ; 
Acidi  phosphorici  diluti,  3ij  ; 
Syrupi  simplicis,  3xiv. 

Sig.  A  half  teaspoonful  or  more  three  times  a  day. 

The  officinal  elixir  ferri,  quininae,  et  strychniae  phosphatis,  now  made 
by  the  best  pharmacists,  often  produces  effects  most  conspicuous  for  good. 
As  a  rule,  all  preparations  of  iron  are  best  omitted  during  menstruation. 

Arsenic  checks  retrograde  metamoq^hosis  and  improves  nutrition. 
It  is  a  good  remedy,  given  in  minute  doses  (gtt.  j-ij)  before  meals,  in 
irritative  dyspepsia,  and  rather  aids  than  otherwise  movements  of  tlie 
bowels  in  chronic  constipation.  In  addition,  it  has  an  excellent  adap- 
tation to  certain  gynecological  affections,  being  indicated  in  a  class  of 
diseases  in  which  iron  is  highly  objectionable.  Chronic  uterine  leucor- 
rhfiea,  cervical  or  corporeal,  and  menorrhagia  de])endent  upon  chronic 
hypcraemia  and  endometrial  fungosities,  are  often  much  bencfitetl  by 


632       THE  INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 

arsenic.  Next  to  ergot  and  quinine,  arsenic  stands  as  a  remedy  for  the 
so-called  chronic  metritis.  It  should  be  given  in  small  doses  (gtt.  iij— 
v)  after  meals  for  a  long  time. 

Phosphorus,  in  the  form  of  the  phosphates,  is  a  very  important  ele 
ment  in  the  nutritive  processes.  Eligible  preparations  are  the  officinal 
syrup,  hypophosphite  comp.,  syrup,  calcis  lacto-phosphite,  etc.  Either 
one  of  these  preparations  may  be  given  where  there  is  defective  activity 
of  the  nutritive  functions,  as  in  ansemia,  malnutrition,  morbid  wake- 
fulness, and  melancholia  the  result  of  cerebral  anaemia  and  exhaustion, 
in  neuralgia,  spinal  irritation,  migraine,  etc.  The  phosphide  of  zinc 
(gr.  -J^,  ter  die)  is  one  of  the  best  preparations  to  secure  the  influence 
of  pure  phosphorus.  All  preparations  of  phosphorus  tend  to  increase 
the  menstrual  flux. 

Cod-liver  oil,  on  account  of  its  power  under  proper  circumstances  to 
facilitate  gastric  digestion,  promoting  the  appetite,  and,  above  all  other 
fats,  forming  the  molecular  basis  of  the  chyle,  is  admirably  adapted  to 
meet  many  of  the  morbid  constitutional  states  found  in  women  with 
chronic  pelvic  disease.  So  soon  as  the  stomach  and  bowels  have  been 
regulated  by  a  proper  diet  and  medication,  cod-liver  oil  should  be  given 
where  there  are  ansemia,  certain  diatheses  and  cachexise,  the  body-weight 
below  the  normal  standard,  and  the  nutrition  below  par.  Anstie  and 
RadclifFe  have  clearly  pointed  out  that  a  diet  of  fats,  especially  cod- 
liver  oil,  has  a  high  degree  of  efficacy  in  many  neurotic  affections. 
Through  its  influence  in  improving  the  general  health  it  is  very  de- 
servedly highly  prized  in  chronic  uterine  diseases.  A  combination  of 
the  hypophosphites  of  lime  and  sodium  with  cod-liver  oil  will  meet 
numerous  indications.  Further  to  increase  the  assimilation  of  fats, 
cod-liver  or  olive  oil  or  cocoa  cream  may  be  introduced  into  the 
body  by  inunction  after  a  Avarm  bath  at  bedtime  or  after  general  mas- 
sage. From  one  to  two  ounces  daily  may  be  incorporated  in  this  way. 
Such  treatments  soon  begin  to  show  their  eifects  in  increased  weight 
and  improved  appearance. 

Electricity,^  in  the  form  of  both  the  faradic  and  the  galvanic  currents, 
is  very  often  utilized  for  chronic  uterine  diseases.  A  marked  physiolog- 
ical effect  of  electricity  is  to  promote  and  increase  the  menstrual  flux, 
irrespective  of  Avhether  it  is  applied  locally  or  generally.  It  is  there- 
fore doubtless  to  be  withheld  in  some  conditions  of  menorrhagia,  while 
indicated  in  the  amenorrhoeic.  Galvanization  of  the  central  sympa- 
thetic, the  cord,  or  the  pelvic  regions  will  at  times  very  favorably 
affect  dysmenorrhoea  of  the  neurotic  t.Aqoe. 

Systemic  massage  has  been  proven  to  be  one  of  the  best  tonics.     It 
consists  in  a  systematic  exercise,  by  friction,  kneading,  tapping,  and 
passive  motion,  of  all  the  muscles,   of  both  the  extremities  and  the 
'  See  article  on  "  Electi'icity." 


CURU.SIV  MKTniTIS,   KIV.    (jF   TlIK    irilllf^.  (;;;;» 

trunk,  f'n)in  h;ilf'  an  lutur  to  an  lionr,  once  to  twite  daily.  I"ii~t  tlu' 
t'xritation  ol"  tlic  ciitanctMis  circnlatitm  is  folhtwctl  hv  a  j^cncial  rise 
of  teinpciatiiic  ;  tlic  iniisclcs  arc  l)r(iiiuli(  into  most  active  exercise  with- 
out the  c\|>cn»litiirc  »»1"  ncrvc-force  ;  tlicn  there  is  an  acceleration  in  all 
the  organic  functions  and  a  <2;radual  increase  of  weiuht.  A  most  nuu'ke*! 
ini|truvcmcnt  in  the  \arious  morbid  plicndMicua  of  the  nervous  system 
follt»ws.  Local  tenderness  and  pains  <lisaj)j)car ;  a  pleasant  sense  <»f 
exhaustion,  and  with  it  a  refreshing  sleep,  is  manifest.  Faradization 
and  nuissage  combined  form  the  two  most  valuable  means  «jf  exercisini^ 
the  nuiscles.  The  "ood  effects  of  exercise  are  obtained  with  exertion. 
Successful  results  with  massairc  or  massatre  and  electricity  require  the 
employment  of  a  trained  rubber — a  ma^tseuse. 

S.  Weir  Mitchell  of  Philadelphia  has  obtained  some  surprisin<rlv 
good  results  from  j::eneral  nuissage,  conjoined  with  exclusion,  rest,  diet, 
and  electricity.  Each  of  these  has  been  utilized  by  others,  but  to 
Mitchell  is  due  the  credit  of  first  scientifically  com1)ining  these  differ- 
ent means  into  one  common  therapeutic  system  of  treatment.  W.  S. 
Playfair  of  London  has  also  published  accounts  of  some  ca.ses  equally 
wonderful,  and  many  other  ]>hysicians,  instructed  by  ^litcheH's  teach- 
ings, have  been  able  to  confirm  his  results. 

The  typical  cases  most  likely  to  be  benefited  by  massage  are  those  of 
long  standing,  who  are  bedridden,  wasted,  hysterical,  with  a  variety-  of 
simulated  disorders.  Such  patients  have  ])rol)al)ly  dragged  out  for  years 
a  miserable  existence  in  chronic  invalidism.  In  many,  though  bv  no 
means  all,  as  some  might  su]>]>ose,  there  is  some  local  disease,  and  from 
this  starting-point  the  invalidism  conuuenced  ;  but  the  resulting  general 
disturbance  has  at  last  become  so  great  as  to  completely  overshadow 
the  local.  Every  endeavor  at  an  amelioration  by  further  local  treat- 
ment or  general  medication  is  utterly  useless.  Playfair  has  Avell 
remarked  that  the  worse  the  case  is,  the  more  easy  and  certain  it  is 
of  cure  by  the  Mitchell  plan  of  treatment. 

There  are,  however,  not  a  few  cases  of  neurasthenia,  debility,  and 
wasting  in  women,  consequent  on  some  chronic  uterine  ailment,  not 
confined  to  bed  or  the  house,  Avhich  may  be  much  benefited  by  massage 
or  massage  with  electricity  and  a  full  diet,  but  with  partial  rest  and 
without  seclusion.  The  different  features  of  this  plan  of  treatment  may 
be  variefl  to  suit  individual  cases.  In  addition.  th<»se  who  are  fat,  with 
flal)by  muscles,  slugsrish  circulation,  are  improved  by  massage. 

The  successful  use  of  massage  requires  skill,  otherwise  it  may  be 
hurtful.  It  is  the  principle  of  the  rest-cure  which  should  be  aime<l 
at  in  all  cases  ;  the  details  are  applied  with  many  modifications.  The 
execution  of  these  details  to  obtain  successful  results  implies  infinite 
tact,  great  patience  and  perseverance,  and  gentleness  combined  with 
firmness. 


634       THE  INFLAMMATORY  AFFECTIONS   OF  THE    UTERUS. 

A  course  of  massage,  electricity,  and  rest  should  always  be  followed 
up  by  a  well-regulated  regimen,  dietary,  and  exercise.  Special  symp- 
toms seldom  require  special  attention.  The  general  and  local  treatment 
is  addressed  to  the  underlying  morbid  states  and  the  faulty  habits  pro- 
ducing these  symptoms.  When  the  former  are  corrected  the  latter,  in 
turn,  abate.  The  temptation  is  always  strong,  and  the  physician  is  too 
often  persuaded,  to  resort  to  the  various  anodynes  to  arrest  pain.  The 
excessively  frequent  practice  of  the  administration  of  opiates — morphia 
hypodermatically  in  particular — because  there  is  pain,  without  an  inves- 
tigation of  its  cause,  is  one  of  the  crying  evils  of  medical  practice  of 
to-day.  Except  for  acute  pain  due  to  inflammatory  action  or  after  a 
surgical  operation  opiates  are  really  seldom  needed.  They  are  danger- 
ous remedies  for  the  chronic  uterine  diseases,  and  their  use,  once  com- 
menced, soon  begets  a  subjective  erethism  and  neuralgia  as  difficult  to 
overcome  as  the  original  affection.  Every  discomfort  is  dwelt  upon 
and  magnified ;  the  drug-intoxication  is  the  only  solace.  But  difficult 
as  it  is  to  resist  the  imperious  cravings,  dependence  upon  these  drugs 
must  be  broken  up,  otherwise  the  case  is  ho23eless. 

Almost  equally  pernicious  is  the  habit  of  prescribing  opiates,  chloral, 
and  the  bromides  to  produce  sleep.  The  last  named  are  the  least  objec- 
tionable, but  their  use  should  never  be  depended  upon  for  any  length- 
ened period.  The  bromides  are  vaso-constrictors  and  depressors  of 
reflex  action ;  hence  they  prove  to  be  our  most  reliable  remedies  for 
the  reflex  neuroses,  psychical  or  physical.  Sleep,  of  which  an  abun- 
dance (eight  to  nine  hours)  is  daily  needed,  should  be  obtained  by  reg- 
ular habits,  proper  food,  plentiful  amount  of  exercise,  massage,  elec- 
tricity, a  cool  and  well-ventilated  room,  and  self-control. 

General  nervousness  or  nervous  excitability  is  gradually  controlled 
by  a  removal  of  the  cause,  proper  hygienic  measures,  and  such  tonic 
medication  as  the  special  indications  call  for.  The  use  of  the  stronger 
alcoholic  stimulants  under  these  circumstances  is  greatly  to  be  deplored. 
Save  the  lighter  wines  or  malt  liquors,  and  these  only  with  food  (the 
heavier  meal),  and  under  conditions  to  which  attention  has  been  directed, 
all  alcoholic  stimulants  ought  to  be  interdicted,  for  they,  like  the  opiates, 
are  unsafe  agents  in  the  hands  of  invalids. 

Headaches  of  the  neurotic  type  are  best  treated  by  quinine,  strychnia, 
arsenic,  phosphide  of  zinc,  cannabis  indica,  and  iron  during  the  inter- 
val, and  by  caffeine,  the  bromides,  and  galvanization  in  the  attack; 
'those  of  the  congestive  form,  by  the  bromides,  belladonna,  etc. 

Many  of  these  suggestions  in  general  management  may  seem  com- 
monplace and  unnecessary,  but  to  one  who  has  had  much  personal  con- 
tact with  such  diseases  in  their  manifold  forms  there  is  nothing  in  the 
least  promising  which  should  be  deemed  unworthy  of  trial.  The  patient 
must  manifest  an  intelligent  co-operation.    The  utmost  regularity  in  all 


CUlioSlc   MKTIUTIS,    h'TC.    OF   THE    UTIJU'S.  (J.;') 

lial)its  and  iliillil'iilncss  in  the  obstTvance  lA'  all  (lircction.s  arc  rcijuisito. 
Kverv  (U'tail  is  important,  and  lie  wlu)  j^lvcs  most  liced  to  fadi  is  tin* 
one  who,  other  thiiijis  hein^-  e(|iial,  meets  with  the  most  j»romj)t  and 
best  sneeess,  ('hroni(!  diseases  reijuire  a  ehi'om'e  treatment.  There  ran 
be  no  restoration  of"  the  local  so  lon;^  as  tliT'  ji'eneral  health  is  deran;ied. 
Tile  reeij)roeal  relations  between  the  two  are  so  stronjr  and  intimate 
that  a  permanent  improvement  in  the  one  can  only  be  eoe.\tensi\c  with 
the  other. 

In  no  class  of  diseases  is  it  more  incinnbcnt  n])()n  the  j»hysician  to 
brin<2.-  to  bear  the  inflncnces  of"  a  moral  treatment.  His  own  maimer 
shonld  be  eheerfnl,  hopef'nl,  and  inspirinji;.  A  personal  ma<^netism 
counts  in  no  small  degree  iu  oreatino;  a  confidence  so  necessary  to  enlist 
the  proper  interest  and  intelligent  co-operation  of  one  long  sick.  To 
divert  the  invalid's  mind  from  herself  and  her  condition,  to  direct  her 
thonghts  into  new  channels,  to  enable  her  to  exercise  the  most  health- 
fnl  discipline  of  self-control,  is  by  no  means  ever  an  ea.sy  task,  b»it 
when  well  done  may  accomplish  more  than  medication  in  restoring 
lost  health. 

So  extended  is  the  sphere  of  the  application  of  remedial  agents  in  the 
constitutional  management  of  the  diseases  under  consideration  that  a 
thorough  knowledge  of  the  whole  field  of  medicine  embraced  is  requi- 
site. To  survey  the  system  at  large,  to  recognize  the  true  import  and 
significance  of  special  symptoms,  to  detect  disease  in  kind  and  degree 
wherever  found,  must  needs  be  the  office  of  the  gynecologist.  Xo  class 
of  affections,  the  body  over,  possess  so  many  ramifications,  assume  so 
many  phases,  induce  such  general  disturbances  as  do  the  chronic  dis- 
eases of  the  female  pelvic  viscera.  Therefore  no  one  can  be  a  compe- 
tent and  successful  gynecologist  who  is  not  first  a  thorough  physician. 

Bibliography. 

Anstie  :  Neuralgia,  and  the  Diseases  that  Resemble  it,  1871. 

Beard  and  Rockwell  :  Treatise  on  Electricity,  1883. 

Byford  :  Diseases  of  Women,  p.  288. 

Emmet  :  Diseases  of  Women. 

Fothergill:  Indigestion  and  Biliousness. 

Goodell:  "Lessons  in  Gynecology"  and  "Neurasthenia  and  AVonih  Diseases,"  -Iwi. 

Gyrwcolog.  Soc.  Transac,  vol.  iii. 
Hewitt,  Graily :  "Chronic  Starvation  and  Delicate  Females,"  Ciu.  Lancet,  Oct.  H, 

1883. 
Mitchell,  S.  Weir  :  Fat  and  Blood,  1884. 
Pavy  :   On  Food  and  Dietetics. 
Playfair  :  Nerve-Prostration  and  Hi/steria. 
KoBERTs;,  William:  Lumleian  Lectures. 


SUBINVOLUTION   OF  THE   UTERUS  AND 

VAGINA. 

IJv  TIIAI)I)i:rs  A.   liKAMV.   A.  M..  .M   D.. 
Cincinnati,  <). 


Subinvolution  of  the  Uterus. 

NoMExn.ATUUE. — MiU'Ii  confiision  lias  existed,  and  still  exists, 
regardinjj:;  the  i-elatious  of  this  aliection  aud  chroiiie  metritis,  aud  the 
nomenclature  is  faulty. 

Some  authorities  helieve  in  subinvolution  as  an  entirely  distinct  affec- 
tion, while  others  believe  it  to  be  only  the  first  step  in  chronic  metritis. 
Consequently,  this  latter  class  when  treating  of  chronic  metritis  really 
include  what  the  former  treat  as  a  sejiarate  ])atholo<2;ical  condition.  While 
no  name  has  been  so  universally  apj)lied  to  defective  reduction  of  the 
uterus  after  parturition  as  "  subinvolution,"  the  condition  has  received 
many  other  desiiiuations  from  the  various  writers  u])on  the  sul^ject. 

In  Sir  James  Simpson's  article  on  "  ]\Iorbid  Deficiency  in  the  Invo- 
lution of  the  Uterus  after  Delivery,"^  read  in  1852,  he  makes  use  of 
the  term  "  subinvolution  "  in  naming  the  condition  of  morbid  deficiency, 
which  was  probably  the  fii'st  time  the  term  was  used.  In  a  jjrevious 
paper  on  the  subject  -  he  first  called  attention  to  such  a  condition,  nam- 
ing it  "  morbid  permanence  of  the  state  of  puerperal  hy])ertroj)hy." 

Klob,  after  a  study  of  the  pathological  changes  and  conditions  found 
in  the  uterus  which  has  not  undergone  perfect  involution,  in  an  endeavor 
to  more  accurately  describe  both  cause  and  condition  calls  it  "  habitual 
hypertemia  with  profuse  proliferation  of  connective  tissue."^ 

Scauzoni,  holding  the  views  of  Sir  James  Simpson  and  many  early 
writers  on  the  subject  respecting  the  infiammatory  cause  of  the  disease, 
styles  it  "  chronic  parenchymatous  metritis."  * 

Most  authors  among  the  French  believe  the  condition  one  of  inflam- 
mation, and  have  generally  employed  the  same  designation. 

Edis"  uses   many  of  the  terms  employed   by  previous  authors,  and 

'  Selected  Obstet.  and  Gyn.Worh,  1871. 

^  Lomlon  and  Kdinbun/h  Medical  Journal,  Nov.,  1843. 

^  Path.  Anat.  of  Female  Sexual  Organs,  1868,  pp.  127  e(  setj. 

*  Disease.^  of  Female.^,  pp.  175  et  i>eq.,  1881. 

*  Diseases  of  Women,  p.  176,  H.  C.  Lea'.s  Son  c*!:  Co.,  Phila.,  1S82. 

6.37 


638  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

treats  the  aifection  under  the  term  *'  chronic  metritis,"  akhough  dis- 
claiming  any  belief  in  its  inflammatory  nature  or  origin. 

Thomas  ^  so  firmly  disbelieves  in  inflammation  as  a  cause  of  the  dis- 
ease that  he  objects  to  any  term  which  conveys  the  idea  that  it  is  in 
any  way  inflammatory,  and  invents  the  term  "  areolar  hyperplasia  "  as 
most  descriptive  of  the  conditions  marking  the  uterus  in  defective 
reduction. 

Hodge  designates  the  condition  "  irritable  uterus/'  from  its  clinical 
aspects. 

Lisfranc  calls  it  "  engorgement/'  to  describe  at  least  one  step  in  its 
etiology. 

Kiwisch  ^  uses  "  infarctus "  as  his  designation,  to  show  the  vascular 
condition  when  involution  is  imperfect. 

Noeggerath,  while  a  disbeliever  in  its  correspondence  to  inflamma- 
tion, thinks  it  should  be  called  "  diffuse  interstitial  metritis." 

Hart  and  Barbour,^  after  quoting  much  of  the  above  nomenclature,, 
although  at  the  same  time  not  believing  it  an  inflammation  in  any  sense, 
adopt  the  old  term  "  chronic  metritis,"  assigning  as  their  reason  for  so- 
doing  that  "  we  are  not  yet  in  a  position  to  propose  a  term  resting  on  a 
sure  pathological  basis." 

Mary  Putnam  Jacobi,*  who  has  written  a  very  able  and  exhaustive 
pa])er  on  the  subject,  calls  this  affection  subinvolution,  and  makes  both 
a  clinical  and  pathological  distinction  between  it  and  chronic  metritis. 
The  recognition  of  such  a  distinction,  which  is  rationally  sustained,  will 
probably  prove  a  basis  for  enlightenment  upon  a  subject  hithertO' 
obscure. 

History. — The  history  of  subinvolution  of  the  uterus — or,  prop- 
erly, its  existence  as  a-  distinct  affection  treated  in  medical  literature — is- 
comprised  in  a  little  more  than  four  decades.  As  a  disease  it  has  cer- 
tainly existed  as  long  as  the  uterus  itself,  but,  like  many  other  disaeses, 
its  recognition  as  a  separate  affection  dates  but  a  few  years  back.  AV  liile- 
there  are  a  few  indistinct  and  general  allusions  to  an  enlarged  condition 
of  the  uterus  remaining  after  delivery  by  others,  it  is  to  Sir  James 
Simpson  that  we  are  indebted  for  the  first  accurate  and  well-defined 
information  on  the  subject.  It  is  an  interesting  fact  that  this  distin- 
guished observer  almost  immediately  after  he  devised  his  uterine  sound, 
aud  probably  through  this  additional  means  of  investigation  and  diag- 
nosis, discovered  the  symmetrical  hypertrophy  of  the  uterus  which  is 
so  familiar  to  the  profession  to-day. 

His  first  description  of  his  sound — or  uterine  bougie,  as  he  called  it 

1  Diseases  of  Women,  pp.  307  et  seg.,  H.  C.  Lea's  vSon  &  Co.,  Phila.,  1880. 

2  Klinische  Vortr.,  Prag,  1845,  p.  104. 

'^  Manual  of  OyncecoJogy,  pp.  306  et  seq.,  1883. 
■*  Amer.  Journ.  Obstet.,  Aug.,  1885. 


suiifwoLrrioy  of  riii:  rrr.iirs.  0,39 

— appeared  in  llic  Aiimist  miiiilici-  <•!'  llic  Lniidnn  (iml  IjHiilm rt/li 
Mdiif/i/i/  JoKnui/  (A'  1<S};5.  Ill  the  .\(>vciiil)cr  miiiiiIki"  of  thai  Joni-nnl 
Cor  the  same  year  is  a  pa|)cr  IVoni  liis  pen  in  wliicli  lie  first  calls  atten- 
tion |()  >iil)inv(>liiii()ii  iiiMJcr  till'  lit  le  "  Tlie  Morltid  I'eniiaiieiiee  ol"  tli(; 
State  (if  I'nerpeial  1 1  \|)ertrnpliy."  In  tlie  ahoN'e-inentioiied  artiele  lie 
inndcstly  asserts  liiinselC  as  the  first  in\-estii:at<»r  in  this  field  in  the  fol- 
low iiiii"  words :  "  This  |)c(iiliar  eondition  does  not  ap])ear  to  lia\'e  as  yet 
attracted  the  attention  of"  obstetric  patiiolo^ists  as  the  cause  of  one  of 
those  forms  of  chroiii(;  hv])oiiastric  tumors  that  ai'c  occasionally  met 
with  diiriiiLi'  the  first  weeks  and  months  after  deliNcry.'  Then,  as  an 
apology  for  his  predi'cessor.s  in  the  field  of  gyneeolotiv  not  havinji'  Ween 
able  to  reeognizi^  and  describe  so  patent  a  disease,  he  continues:  "The 
want  of  any  decisive  means  of  recoo-niziiiu-  it  has  doubtless  led  to  this 
omissiou."  Tlie  decisive  means  here  referred  to  was  the  sound  of  his 
own  device,  to  which  he  ascribes  the  honor  of  discoverinj^  the  character 
of  these  so-ealletl  "chronic  hypogastric  tumors,"  which  were  so  fre- 
quently noticed,  and  whose  mysterious  disappearance  was  either  a  puz- 
zle to  gyuecologists  or  attributed  to  the  various  remedies  which  were 
administered  for  their  cure.  However,  there  are  few  gynecologists  at 
the  present  day  who  would  invoke  the  aid  of  the  uterine  sound  in  diag- 
nosis of  this  condition. 

Immediately  after  the  publication  of  the  article  mentioned  many 
observers  began  to  investigate  the  subject,  but,  so  far  as  can  be  ascer- 
tained, nothing  new^  was  offered,  and  the  disease  was  simply  accepted  as 
a  morbid  permanence  of  puerperal  hypertrophy. 

In  1851,  Dr.  Snow  Beck  described,  microscopically,  the  same  condi- 
tion in  a  paper  read  before  the  ^Medical  Society  of  London,  A])ril  12, 
1851,  but  made  no  reference  to  Simpson's  discovery  in  1843.  He  sim- 
ply called  it  "  a  new  disease  of  the  uterus."  His  paper  contained  an 
account  of  the  microscopic  examination  of  a  uterus  from  a  woman  who 
had  died  a  considerable  time  after  delivery,  which  was  found  post-mor- 
tem to  be  greatly  enlarged.  He  says  the  uterine  tissue  did  notappear 
to  the  microscope  to  contain  any  inflammatory  or  abnormal  dej)osit. 
The  muscular  tissue  appeared  to  hold  a  medium,  position  between  that 
of  the  impregnated  uterus  and  the  muscular  tissue  of  the  gravid  organ. 
He  concludes  as  follows  :  "  These  facts  pointed  to  the  conclusion  that 
this  aflfeetion  had  its  origin  in  an  arrest  of  the  due  absoi-ption  which 
naturally  follows  parturition."  These  conclusions  may  be  said  to  be 
the  same  readied,  as  to  the  etiology  of  the  affection,  by  Simpson  and 
most  subsequent  observers  up  to  the  time  of  Dr.  Beck's  paper.'  Indeed, 
the  reduction  of  the  uterus  after  delivery  was  ascribed  to  fattv  d(>oen- 

^  Since  tlie  woman  from  wliom  this  uterus  was  obtained  died  of  typlnis  fever,  and 
since  tlie  microscopic  details  are  very  incomplete,  it  is  doubtful  whether  the  case  throws, 
any  light  upon  the  subject  of  subinvolution. 


640  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

eration  before  Simpson's  discovery,  aud  the  general  belief,  that  the  dis- 
ease was  due  to  a  deficient  absorption,  was  quite  natural. 

Dr.  Lever'  refers  to  cases  of  defective  involution  as  a  "  morbid  per- 
manence of  the  state  of  puerperal  hypertrophy,"  aud  quotes  as  his 
authority  Sir  James  Simpson's  paper  of  the  preceding  year. 

Simpson,  in  a  note  appended  to  a  later  edition  of  the  paper  referred 
to,  says :  "  Long  after  the  above  was  written  I  met  the  following  passage 
in  Dr.  Hooper's  work,  which  showed  that  the  diseased  state  I  had 
noticed  during  life  was  known  to  him  as  a  post-mortem  appearance : 
'■  When  a  foetus  has  been  recently  expelled,  it  is,  in  some  instances,  a  long 
time  before  the  uterus  returns  to  its  original  state,  and  it  is  larger  and 
softer  during  the  period.  I  have  examined  uteri  four  times  their  nat- 
ural size  from  this  cause  two  months  and  even  more  after  the  foetus  was 
expelled.'  " "  He  also,  in  a  note  appended  to  the  same  article,  asks  the 
following  fjuestion  :  "Is  this  disease  alluded  to  in  Kleinert's  Bepertorium, 
Band  ii.,  1838,  S.  51,  as  described  by  Kopp  under  the  name  of  hys- 
teranesis  in  the  first  volume  of  Denkwurdigkeiten,  p.  1 68  ?  I  regret  to 
say  I  have  no  access  to  this  work."  Thus  it  seems  that  Simpson  him- 
self would  endeavor  to  disclaim  his  right  to  priorit}^  in  the  description 
of  the  disease,  but  to  us  there  can  appear  little  doubt  that  the  honor 
of  discovery  belongs  to  him;  at  least  he  was  first  to  describe  the  con- 
dition in  the  living  subject.  He  described  and  laid  down  rules  for  the 
treatment  which  have  been  very  little  modified  in  forty  years. 

Dr.  Fleetwood  Churchill,^  who  wrote  on  the  diseases  of  women  before 
Simpson's  time,  describes,  as  do  most  other  gynecic  authors  of  his  and 
former  times,  an  inflammation  of  the  uterus.  He  probably  is  describ- 
ing what  Simpson  observed  and  named  subinvolution  when,  in  recount- 
ing the  terminations  which  inflammation  of  the  uterus  may  undergo,- 
he  says :  "  H^^iertrophv  or  induration,  which  appears  to  consist  either 
in  a  temporary  enlargement,  probably  from  afflux  of  fluids,  or  in  a  per- 
manent auo;meutation  of  the  tissues  of  the  womb  itself,  which  may  thus 
be  vastly  increased  in  size."  He  describes  further  the  appearance  of 
such  a  uterus  as  follows :  "  If  a  section  be  made,  the  texture  will  be 
more  or  less  fine  according  as  the  induration  is  temporary  or  permanent, 
and  of  a  reddish  or  grayish  color,  the  surface  being  smooth  and  uniform." 
From  this  I  think  we  are  without  doubt  to  infer  that  he  had  under 
observation  the  condition  of  subinvolution,  but  he  nowhere  assigns  a 
defective  reduction  of  the  uterus  as  a  cause ;  neither,  indeed,  do  I  find 
any  evidence  that  he  understood  in  any  way  the  process  of  uterine 
reduction. 

Still  earlier  than  Churchill,  and  quoted  by  him,  Dr.  Burns*  recorded 

^  Guy's  Hospital  Reports,  vol.  ii.  p.  18,  1844. 

"^Morbid  Anatomy  of  the  Human  Uterus,  p.  5.  ^  Disease,^  of  Females,  1844. 

■*  Quoted  by  Churchill,  op.  cit. 


srni.woi.rTinx  or  nii:  rrr.nrs.  on 

uiuli'i'  the  U\\v  ntiiiolli.s.si iiiciil  a  i'(»iulili(iii  nl'tlic  ulcnis  w  Iiicli  must  have 
Ik'OM  siil)iiiv<iliitit>ii.  TIk'  CnllnwiiiLi'  Mfc  \\]>  uords:  "  SdriK-tiiiics  as  a 
C'onsiHjiK'iicc  of  iiltriiic  iiillainiiialiiiii  iihuc  or  li.-s  (li.~l  iiid  l\-  iiiarkiMl, 
but  occasional  I  \'  wiilmiii  aiiv  \cry  distinct  iiidication  ul'  uterine  diseubc, 
we  find  pari  tn'  tlic  whole  ol'  tlie  woinl)  soi'tened  an<l  its  substance  very 
easily  lorn." 

l)u|)ai"c([ue'  has  observed  a  condition  of"  tilings  (K'scribed  as  follows: 
''The  auto|)sv  ol"  females  who  have  died  of  metritis  shows  the  tissue; 
of  the  Ulei'US  swollen,  reddi>li-biaek,  soflelicd,  IVial^lc ;  the  bhiod  with 
which  it  is  en«>;or<:;ed  is  mixed  with  a  puriform  or  serous  Ihiid."  It  is 
probable  that  these  wore  eases  of  defective  involution  of  the  uterus. 

It  seems,  however,  that  none  of  the  observers  uj)  to  Sir  James 
Simpson  made  out  the  cause  of  certain  enlarged  uteri  ^\■]lich  they  sjiw. 
Althouo-li  in  En<2;land  tliis  disease  has  been  recognized  as  distinct  from 
what  has  usually  been  called  '*  puerperal  metritis"  by  continental 
Avriters,  with  the  exception  of  Courty,^  yet  it  seems  to  differ  from  the 
chronic  parenchymatous  metritis  of  Scanzoni^  and  the  post-puerperal 
metritis  of  C'liomel  only  in  etiology.  jNIost  authorities  have  treated  the 
enlarged  condition  of  the  uterus  found  some  time  after  parturition  as 
subinvolution  or  chronic  metritis,  and  whichever  view  they  have  sup- 
ported has  been  advanced  to  the  exclusion  of  the  other.  Some  have 
held  that  the  chronic  metritis  which  they  sustain  is  almost  if  not 
entirely  identical  with  defective  involution.  Others  maintain  that 
there  is  a  morbid  })roeoss  engrafted  upon  and  due  to  the  })re-existing 
subinvolution  which  they  call  chronic  metritis. 

Mary  Putnam  Jacobi  is  not  an  exclusive  partisan  of  either  view,  but  an 
advocate  of  both.  She  claims  that  subinvolution  and  chronic  metritis 
both  exist  and  ai'e  capable  of  clinical  differentiation,  and  arc  the  results 
of  markedly  diverse  pathological  processes. 

Thus  it  is  seen  that  owing  to  the  confusion  of  terms  and  the  absence 
of  unanimity  on  the  part  of  those  who  have  been  considered  authority 
regarding  the  relations  of  these  affections,  clear  conception  has  not  gen- 
erally been  reached.  It  is  not  improbable  that  more  accurate  know- 
ledge, and  therefore  better  agreement  of  opinion,  await  us  in  the  near 
future. 

From  all  that  has  been  written  upon  the  subject,  ]>robably  the  cor- 
rect inference  is  that  there  is  an  enlarged  condition  of  the  uterus  remain- 
ing after  jiarturition  as  a  result  of  defective  retrogression,  which  has  not 
usually  been  ditterentiated,  either  clinically  or  microsco]>ically,  from 
enlargement  due  to  some  morbid  process  subsequently  added  to  this 
defective  involution.     Since  this  couditiou  of  enlargement  arises  from 

^Quoted  by  C'liurchill,  op.  cif. 

^  Di.«en.«es:  of  Uterus,  pp.  594  et  seq.:  "Ovaries  ami  Fallopian  Tubes,"  1883. 

^  Op  cit. 

yoL.  I. — tl 


642  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

causes  so  dissimilar  in  character,  it  is  fair  to  presume  that  there  are 
diiferences  in  the  conditions  which  have  as  yet  escaped  observation,  and 
there  seems  to  be  thus  good  ground  for  assigning  different  names  to  the 
condition  based  on  its  etiology.  For  instance,  it  is  proper  to  call  that 
enlargement  due  to  defective  reduction  subinvolution,  Avhile  it  would 
be  certainly  irrational  to  call  such  a  condition  due  to  other  cause  by  the 
same  name,  even  though  we  were  unable  to  make  any  other  than  an 
etiological  distinction.  But  since  the  possibility  of  a  clinical  distinction 
appears  to  be  demonstrated,  it  would  be  wise  to  confine  the  term  sub- 
involution to  defective  reduction  pure  and  simple,  and  to  employ  some 
other  term  for  this  superadded  pathological  process ;  and  w'e  cannot  at 
present  do  better  than  to  call  this  state  chronic  metritis,  not  retaining 
the  phrase  simply  in  conformity  to  fashion,  but  because  we  believe  the 
condition  to  be  one  of  chronic  inflammation. 

HiSTOLOaY. — In  order  to  a  better  understanding  of  the  pathology 
of  the  changes  in  the  uterus  in  both  normal  and  abnormal  involution, 
a  brief  study  of  the  histology  of  the  organ  is  necessary. 

While  the  main  points  in  the  histology  of  the  uterus  are  agreed 
upon  by  authors,  some  of  the  minuter  structure  is  still  sub  judice. 
As  a  whole,  the  uterine  walls  may  be  said  to  contain  five  distinct 
classes  of  elements : 

1.  Unstriped  muscle-fibres  of  the  highest  order  and  in  the  highest 
state  of  development.  These  cells  vary  in  length  from  y^S"*-'^  ^^  ^^ 
inch  in  the  unimpregnated  uterus  to  ^th  in  the  gravid  state.  They 
are  for  the  most  part  closely  interlaced  with  each  other,  and  are  arranged 
in  bundles  or  layers,  united  and  at  the  same  time  separated  by  areolar 
tissue.  This  areolar  type  of  connective  tissue  is  more  abundant  at  the 
outer  part  of  the  muscular  walls.  The  muscular  structure  of  the  uterus 
may  be  divided  into  three  layers  wdth  reference  to  arrangement : 

a.  The  outer  of  these  is  a  thin  stratum  lying  immediately  beneath 
the  serous  covering  of  the  organ.  The  bundles  of  this  layer  are  said  to 
arch  across  the  fundus  in  a  longitudinal  direction,  beginning  at  the  cer- 
vix, some  passing  into  the  broad  and  others  into  the  round  ligaments. 

b.  Internal  to  this  is  found  another  thin  stratum  of  muscular  tissue, 
w4iich  is  in  the  posterior  wall,  from  which  its  fibres  run  over  the  fundus 
and  sides  of  the  organ,  and  ramify  among  the  blood-vessels,  which  are 
here  most  numerous.  It  is  also  in  this  portion  that  the  nerve-structures 
are  most  plentiful. 

e.  The  innermost  layer  of  muscle  is  probably  the  part  of  the  uterine 
mucous  membrane  which  corresponds  to  the  muscularis  mucosse  of  other 
hollow  organs.  It  is  much  thicker  than  the  other  layers,  making  the 
greater  part  of  the  uterine  wall.  The  muscular  portion  of  this  muscu- 
laris mucosse  is  so  well  marked  as  to  make  it  distinctly  different  from 
that  portion  of  other  mucous  membranes,  and  to  class  it  properly  as  a 


si'iiLwoLcnoy  OF  TJIJ-:  utj-jju's.  Gi;i 

])()rti()n  of"  tlio  iiuisciiliir  wall.  Its  lihrcs  ai'c  |)('('iili:irly  an"an<;c(l  as  two 
S[)liiiict('rs  surrouiidiiiti'  the  ciilraiicc  of  the  I'^illopian  tiilx's,  wIkisc  most 
external  lihrcs  iiitci-lai'c  with  each  oilier  al  the  aiilei'i(»r  and  posterioi- of 
the  Ciindus,  while  (hey  chanti-e  direction  at  the  eervix  in  sneh  a  manner 
as  to  run  almost  transversi-ly,  lorming  sphineters  at  the  os  internmn  and 
OS  extormini. 

2.  1  Tomot^-cneous  or  amorphous  eounc('tiv(!  tissue,  which  forms  tlie 
areolar  tissue  of  the  muscular  ])art  of  the  walls,  being  i'ouiid  also  in  the 
mucous  mend)rane. 

3.  Fibrillar  connective  tissue,  wliich  assists  in  formint^  the  susten- 
taculum of  the  lymphatics,  accordinti;  to  Leopold.' 

4.  Round,  spindlc-sha|)ed,  and  irregular  cells  imbedded  in  the  homo- 
geneous tissue,  which,  according-  to  Thomas,  are  supposed  to  be  element- 
arv  fusiform  fibre-cells. 

5.  Yellow  clastic  tissue  is  found  in  small  quantity  in  the  mueous 
membrane. 

In  addition  to  these  elementary  constituents,  it  also  has  an  envel- 
oping serous  membrane,  nerves,  bloodTvessels,  and  lymphatics,  and  a 
lining  mncons  membrane.  During  the  gestative  process  the  princij)al 
change  consists  in  a  simple  hypertrophy  whereby  the  mnscle-cells 
enlarge  from  nine  to  eleven  times  their  former  size.  A  numerical 
hypertrophy  is  said  to  occur  in  the  innermost  layer  during  the  first  six 
mouths  of  gestation.  The  arteries,  nerves,  and  veins  also  increase  in 
size,  and  the  structures  of  the  mucous  membrane  participate  in  the 
increase.  The  artei'ies  are  extremely  tortuous  in  their  course  through 
the  uterine  wall,  and  frequently  anastomose  with  each  other.  The 
arterioles  break  up  into  a  fine  capillary  network  near  the  free  sur- 
face of  the  mucous  membrane.  These  capillaries  form  arches  siu'- 
rounding  the  mouths  of  the  uterine  glands  and  lying  immediatelv 
beneath  the  surface  epithelium  of  the  endometrium.  The  veins,  which 
are  very  large  and  sinus-like,  are  exceedingly  thin-walled,  and  lie 
immediately  in  contact  with  the  muscular  structure.  According  to 
Leopold,  the  veins  are  not  nearly  so  numerous  as  the  arterioles  in  the 
mucous  membrane,  although  this  predominance  does  not  persist  in  other 
parts  of  the  uterine  tissues.  According  to  Jacobi,  this  extensive  arrange- 
ment of  surface  capillaries,  curling  arterioles,  and  tortuous  arteries,  with 
the  large  and  dilatable  veins,  tends  to  prolong  the  abode  of  the  blood  in 
the  uterine  mucosa,  thus  conducing  to  growth  of  the  endometrium  in 
menstruation  and  pregnancy.  There  is  a  subepithelial  stratum  of  embrv- 
onic  tissue,  consisting  of  round  cells  and  free  nuclei,  without  anv  definite 
arrangement  with  reference  to  the  surrounding  or  imbedded  glands  and 
vessels.  According  to  the  Hoggans,^  the  lymphatics  begin  within  this 
tissue,  directly  under  the  surface  epithelium,  like  the  lacteals  of  a  villus. 

'  Arch.  f.  Gi/n.,  vol.  xii.  *  Obsict.  Transactions,  London,  p.  4,  1881. 


644  SUBINVOLUTION  OF  THE    UTERUS  AND    VAGINA. 

Between  these  csecal  lymphatics  and  the  epithelium  of  the  uterine  glands 
nothinsi;  intervenes. 

According  to  LeopokP  and  De  Sinety/  the  lymphatics  begin  in  this 
subepithelial  embryonal  tissue  as  endothelial  lined  connective-tissue 
lymph-spaces.  According  to  both  views,  these  intercommunicate,  and 
ultimately  enter  the  subserous  and  periuterine  lymphatics,  and  accord- 
ing to  either  view  they  are  left  lying  patulous  at  the  end  of  parturition, 
and  to  a  less  extent  also  at  the  end  of  menstruation. 

Pathology. — The  condition  of  the  pathology  of  this  subject  is  so 
crude  that  Thomas Mn  his  last  edition  says  of  it:  "  The  literature  is 
scanty  in  the  extreme  as  yet,  and  the  subject  awaits  extended  researches 
before  we  can  speak  intelligently  of  it."  It  is  now  four  years  since 
this  distinguished  authority  wrote  these  words,  and  to-day  there  seems 
very  little  to  change  the  conclusion  then  reached. 

Hart  and  Barbour  in  an  edition  only  a  year  old,  as  already  cited, 
say,  in  referring  to  chronic  metritis,  "  We  are  not  yet  in  a  condition  to 
select  a  name  resting  on  a  sure  pathological  basis." 

Jacobi  (in  August,  1885)  says:  "It  should  not  be  too  difficult  to  iind 
specimens  of  chronically  subinvqluted  uteri  ....  without  the  second- 
ary connective-tissue  change.  But,  so  far,  these  do  not  seem  to  be 
reported,  and  we  are  reduced  to  inference  from  the  appearance  of  the 
accessible  portions  of  the  uterus  and  from  the  clinical  symptoms." 

Indeed,  although  it  seems  a  libel  on  our  boasted  investigation  of  the 
past  forty  years,  not  much  has  been  added  to  the  pathology  of  this 
subject  since  the  last  paper  on  subinvolution  by  Sir  James  Simpson. 
He  made  the  declaration  that  "  this  retrograde  metamorphosis  of  the 
uterus  has  not  taken  place  during  the  puerperal  month,  Or  has  taken 
place  only  to  such  an  imperfect  degree  that  the  uterus  is  of  the  size 
we  usually  see  it  at  the  end  of  the  first  week  or  so  after  delivery." 
Without  attempting  a  minute  description  of  the  pathological  changes 
and  conditions  to  be  found  in  such  an  organ,  he  says :  "  Subinvolution 
is  due  to  any  arrest  of  the  fatty  degeneration  or  subsequent  absorption 
from  whatsoever  cause;"  from  which  we  are  to  infer  that  his  idea  was 
that  the  microscope  would  disclose  a  general  fatty  degeneration  in  a 
subinvolution  of  the  uterus  at  any  time  during  the  existence  of  the 
condition.  Schroeder  says  that  "  arrest  of  puerperal  involution  is  rarely 
a  pure  hypertrophy,  but  a  change  in  which  the  fatty  degeneration  occurs 
normally,  but  absorption  fails  and  new  muscular  fibres  are  not  formed. 
The  wails  are  thick,  soft,  and  flabby.  The  uterine  tissue  is  grayish- 
yellow  or  yellowish-red  in  color,  very  friable,  and  delicate  mucous 
threads,  like  spider-webs,  stretch  across  the  laceration."  These  words 
are  in  Schroeder's  article,*  but  are  quoted  from  Klob.'     Thus  it  would 

1  Archivfiir  GyndL,  Bd.  vi.         '  Quoted  by  Jacobi,  loc.  cit.  {Mai.  des  Fern.,  p.  256). 
3  Op.  cit.,  p.  sis.  *  Ziemssen,  vol.  x.  p.  73,  1874.  ^  Op.  cit,  p.  128. 


suiu.w'nij'Tiox  or  'nil',  rrmtrs.  645 

;i|t|t(:ir  dial  his  |»atlin|(iMv  afcnrds  in  llic  main  willi  Simpson's  in  inal<- 
in"'  the  cnndition  one  of  I'atlv  dci^cncralitm.  Il  i.--  dillicnll  to  liarmo- 
iii/r  till'  above  description  widi  sonic  later  ol)scr\atioiis  ol"  l\loli  on  this 
conilidon,  c.\cc[>t  1>\-  supposing;-  thai  lie  is  descrihin;;-  a  later  .sta<^e  of  the 
disease  correspoiidiiii;'  to  chroiiic  metritis,  lie  says:  "  The  whole  ute- 
rine c(miieeti\-e  tissue  sometimes  proliferates,  either  with  accompanyin}^ 
iiKirease  of"  the  nniscular  siihstaiici',  or,  if  this  does  occur,  the  eoiiiiec- 
tive  tissue  predoiiiiuates  to  such  an  extent  that  the  muscular  substance 
is  comparativelv  ot"  not  much  account."  Later  on  he  says:  "The 
newlv-loiMucd  connective  tissue  is  chiefly  c()m[)ose(l  of  thin  lihi'ils  <lc- 
liciiMit  in  nuclei,  which  cross  the  uterus  in  lines  of  various  breadth  in 
all  directions,  I'orming-  a  coiiiplicated  felt-like  ne[\v(;i-k  and  constitutin;^ 
the  greater  substance  of  the  uterus.  In  the  first  stjiges  of  the  disease 
the  muscular  fibres  are  broader  and  hypertrophied,  but  at  a  later  period 
may  be  conij)letely  lost  in  the  proliferation  of  connective  tissue." 

After  parturition  the  uterus  rapidly  decreases  in  size,  until  in  four  to 
six  weeks  it  has  reached  its  former  weiti'ht,  or  as  nearly  so  as  it  will  ever 
do.  This  change  is  agreed  to  be  the  result  of  the  fatty  degeneration  of 
the  nniscular  fibres,  with  the  subsequent  absorption  of  this  fat  and  its 
partial  voidaiice,  together  with  the  degenerated  mucous  membrane,  by 
way  of  the  lochia.  These  are  the  means  by  which  involution  is  secured. 
During  the  period  of  gestation  the  work  of  the  uterus  has  been  chiefly 
one  of  growth,  -which  has  brought  about  the  general  muscular  hyper- 
troi)liy. 

When  labor  begins  the  process  of  "growth  is  charged  to  function"^ 
for  the  expulsion  of  the  uterine  contents.  The  venous  hyperjemia, 
which  was  sufficient  for  growth,  has  given  place  to  the  increased  blood- 
supply,  which  constitutes  the  arterial  hypersemia  of  function.  The 
muscular  fibres,  which  have  so  enormously  increased  both  in  number 
and  size,  have  up  to  this  time  been  supplied  with  only  blood  enough  to 
maintain  their  growth  and  life,  and  have  lain  comparatively  dormant. 
At  the  beginning  of  labor  the  increased  nutrition  furnished  by  the 
copious  afflux  of  arterial  blood  stimulates  these  cells  to  their  proper 
function  of  contraction  until  the  uterus  is  emptied.  The  continued 
contraction  of  the  muscular  fibres  cuts  off  much  of  the  arterial  su]>jdy, 
and  veuoiLs  stagnation  ensues  to  such  an  extent  that  even  the  nutrition 
neeessaiy  to  the  integrity  of  the  cells  is  removed.  Fatty  degeneration 
consequently  occurs  as  an  expression  of  this  impaired  nutrition.  Xot 
only  are  the  large  muscle-cells  broken  down  by  the  fatty  degeneration 
of  imjKiired  nutrition,  but  also  by  that  cellular  change  which  occurs 
from  the  increased  oxidation  resulting  from  the  contractions  of  labor. 

Fatty  degeneration  begins,  according  to  Heschl,-  about  the  fourth 
day.     It  is  seen,  however,  from  the  above,  that  the  processes  leading  to 

^  Jacobi,  Am.  Journ.  Obst.,  1885.  ^  Review  in  Arch,  ck  Med.,  1854. 


G46  SUBiyVOLUTION  OF  THE   UTERUS  AXB   VAGINA. 

this  condition  commence  witli  the  inception  of  labor.  The  fat,  the 
product  of  this  change,  is  partly  absorbed  bv  the  general  cii'culation 
and  partly  escapes  from  the  mouths  of  the  open  lymphatics  of  the 
endometrium  as  a  contribution  to  the  lochia. 

It  is  a  well-known  clinical  fact  that  subinvolution  of  the  uterus  to 
a  greater  or  less  degree  is  prone  to  occur  in  women  who  have  suffered 
from  jDuerperal  metritis,  perimetritis^  peritonitis,  or  some  other  mani- 
festation of  septicaemia.  In  most  of  these  subjects  the  lochia  was 
greatly  diminished  or  completely  suppressed.  It  is  legitimate  to  infer 
that  in  these  cases  the  lochial  suppression  may  bear  a  causal  relation  to 
the  subsequent  subinvolution^  since  so  much  of  the  degenerated  uterine 
tissue  as  would  have  thus  been  disposed  of  must  remain  or  be  eliminated 
by  other  channels.  Since  there  is  no  authority  for  considering  subin- 
volution a  permanent  fatty  degeneration  of  the  uteruus,  inasmuch  as  no 
investigator  finds  fat  in  any  considerable  quantity  in  such  a  diseased 
organ,  we  are  to  infer  that  fatty  degeneration  has  not  occurred,  or  that 
it  has  occurred  and  subsequently  been  absorbed  or  changed  into  the  class 
of  tissue  found  in  the  subinvoluted  uterus. 

As  has  already  been  noticed,  Simpson  and  Schroeder  seem  to  be  of 
the  opinion  that  the  enlargement  is  due  to  unabsorbed  fat  in  the  uterine 
walls  when  they  say  that  the  affection  is  due  to  interference  with  the 
absorption  of  fatty  degenerated  muscular  tissue ;  but  there  appears  to 
be  no  microscopic  authority  for  such  conclusion. 

Dr.  Snow  Beck^  found  that  "the  enlargement  of  the  organ  was  due 
to  the  great  increase  of  the  round  and  oval  bodies,  with  amorphous  tis- 
sue in  the  uterine  walls  as  well  as  at  the  inner  surface,  which  form  the 
soft  tissue  of  the  uterus,  aided  by  an  enlargement  of  the  vessels."  He 
also  found  no  relative  increase  in  the  amount  of  muscular  tissue  ;  or,  in 
other  w^ords,  agrees  w'ith  Klob  in  the  absence  of  muscular  hypertrophy. 

There  is  indeed  room  to  doubt  whether  this  was  a  pure  and  simple 
case  of  subinvolution,  for  the  patient  died  of  typhus  fever  and  her  pre- 
vious clinical  history  is  not  given.  Jacobi  thinks  it  may  have  been  "  a 
round-celled  infilti'ation  of  the  uterus  under  the  influence  of  typhus 
fever."  According  to  Jacobi's  method  of  differentiating  subinvolution 
from  chronic  metritis  by  the  depth  of  the  uterine  cavit}=^,  the  presump- 
tion is  in  favor  of  the  latter,  for  the  cavity  in  this  case  was  but  three 
inches  deep,  and  she  states  that  in  subinvolution  the  cavity  measiu-es 
from  nine  to  fourteen  centimeters  (3.6  to  5.6  inches). 

Finn's  observations^  are  diametrically  opposed  to  Klob,  Beck,  Scan- 
zoni,  De  Sinet}^,'  and  all  others,  and  make  the  diseased  state  due  to 
muscular  hypertrophy  and  hyijerjilasia,  claiming  that  the  muscle-cells 
are  both  increased  in  size  and  number.     He  also  states  that  the  con- 

^  London  Obst  Trnns.,  vol-,  xiii.  ^  Amer.  Journ.  Obstet,  vol.  i.  p.  264. 

"  Oyncecol,  pp.  315,  351,  1879. 


sriiixvoij'Tioy  or  the  rrrnus.  <>47 

iioctive  tissue  is  ri'hitivi'iy  (limiiiislicd.  Finn's  report  is  on  elironie 
metritis,  and  subinvolution  is  not  eonsidered,  altliou<^li,  sinee  liis  i-esulls 
ditJ'er  so  manifestly  iVom  those  of  otiiers  wlio  have  made  pathohjgical 
investiji'ations  of  uteri  alleeted  witli  chronic  metritis,  it  may  be  i)re- 
sumeil  that  his  ease  was  not  that  disease,  l)ut  some  condition  (x-'cupying 
a  j)osition  between  the  muscular  hypertropliy  of  the  gravid  state  and 
the  connective-tissue  liyperplasia  of  well-marked  ciiroiiic  metritis. 

Jacobi  thinks  this  description  coincides  with  what  we  may  infer  from 
the  clinical  symj)toms  and  the  pliysical  condition  of  the  uterus  iu  sub- 
involution, or  as  ''a  first  form  of  chronic  metritis  entirely  distinct  from 
inflammation."  Thomas  accounts  for  the  great  diiference  between  Finn's 
views  and  those  of  others^  in  the  time  after  parturition  when  the  inves- 
tigations were  made,  and  says  that  he  who  examines  early  will  prol)ably 
find  a  greater  amount  of  muscular  tissue  than  he  who  does  so  later. 

De  Sinety,  in  treating  chronic  metritis,  compares  its  stages  and  micro- 
scopic pictures  to  those  observed  in  hepatic  cirrhosis — an  early  soft, 
large,  hyperremic  stage,  and  a  later  hard,  small,  anaemic  stage.  He 
says :  ^  "  Iu  the  first  stage  the  dominant  lesion  is  the  presence  in  great 
numbers  of  embryonic  elements  throughout  the  whole  thickne&s  of  the 
muscular  walls.  These  elements  are  met  with  specially  round  the  blood- 
vessels or  form  islands  of  variable  dimensions  which  are  more  or  less 
apart.  The  second  period  is  characterized  by  two  changes:  1,  marked 
dilatation  of  the  lymphatic  spaces;  2,  a  localized  hypertrophy  of  the 
connective  tissue.  The  sclerosis,  for  such  it  may  be  called,  differs  from 
a  similar  change  in  the  kidney  and  liver  in  the  fact  that  the  formation 
of  the  connective  tissue  is  localized  round  the  blood-vessels."  He  is 
unable  to  say  whether  the  muscular  tissue  was  normal  or  diminished  in 
quantity. 

Mary  Putnam  Jacobi  ^  has  made  a  very  careful  study  of  the  uterus 
of  a  woman  who  died  eight  days  after  parturition,  in  which  she  found 
the  muscular  fibres  either  hypertrophied  with  nuclei  indefinable  and 
disappearing,  or  smaller  fibres  with  indistinct  central  nuclei,  others  still 
smaller  Avitli  nuclei  distinct,  while  a  fourth  variety  without  nuclei  were 
granular  and  contained  oil-globules.  In  all  these  the  feeble  manner  in 
which  the  extremities  of  the  filires  took  up  coloring  matter  seemed  to 
indicate  that  the  wasting  of  the  cell  l^egan  in  the  protoplasm  and 
attacked  the  nucleus  last.  Among  these  fibres  were  nucleated  con- 
nective-tissue cells  and  amor])hous  tissue.  The  blood-vessels  and  lym- 
phatics were  much  enlarged  and  in  immediate  contiguity  with  the  nnis- 
cular  tissue,  which  is  markedly  different  from  the  perivascular  condition 
observed  by  herself  and  De  Sinety  in  cases  of  chronic  metritis. 

The  same  author  also  details  her  own  results  from  the  examination 
of  the  uterus  in  a  state  of  chronic  metritis,  and  her  observations  in  the 
1  Op.  cit.,  p.  312.  2  Op.  cit.  '  Loc.  cit. 


648  SUBINVOLUTION   OF  THE    UTERUS  AND    VAGINA. 

main  coincide  with  those  of  De  Sin6ty.  She  says  :  "  The  three  promi- 
nent lesions  found  in  either  body  or  cervix  of  the  uterus  in  metritis  are 
— enlargement  and  multiplications  of  blood-vessels,  dilatations  of  lym- 
phatics, proliferation  of  scantily-nucleated  connective  tissue,  chiefly 
around  both  sets  of  nutritive  canals,  but  also,  to  some  extent,  between 
bundles  of  muscular  fibres,  and  even  within  these  bundles.  In  the 
hypertrophied  cervix  this  tissue  has  been  found  even  to  replace  mus- 
cular fibre  to  a  considerable  extent." 

For  such  appearances  as  these  to  be  derived  from  those  found  in  a 
uterus  eight  days  after  delivery  she  infers — 

"1.  That  from  the  subinvolved  uterus  the  ribbon-shaped  fibres,  as 
also  those  filled  with  fat-granules  and  all  the  intermediate  forms, 
together  with  the  cells  and  granules,  finally  disaj^peared. 

"  2.  That  the  lymphatic  spaces  and  blood-vessels  remained  abnor- 
mally large. 

"  3.  That  the  walls  of  the  enlarged  blood-vessels  finally  suifered 
some  structural  alteration,  in  virtue  of  which  nutritive  transudations 
of  an  albuminous  plasma  took  place,  which  gradually  caused  a  local 
development  of  connective  tissue  (perivascular  sclerosis).  It  is  this 
perivascular  sclerosis  which  constitutes  the  cardinal  difference  between 
a  pure  subinvolution  and  a  chronic  metritis  grafted  upon  it." 

The  question  as  to  whether  this  process,  chronic  metritis,  is  an  inflam- 
mation or  not  is  very  old  and  much  worn.  The  authority  just  quoted 
believes  that  it  is ;  and  it  certainly  seems  clear  that  the  results  of  the 
disease,  as  shown  in  the  latest  researches  of  the  microscope,  manifestly 
place  it  in  the  category  of  inflammations.  While  the  phenomena 
observed  in  a  uterus  aifected  by  this  disease  do  not  wholly  concur  with 
chronic  inflammations  in  other  organs,  they  certainly  as  nearly  approach 
such  concurrence  as  might  be  expected  when  we  consider  the  marked 
difference  in  the  structure  of  the  uterus  as  compared  with  other  organs. 
The  presence  of  the  perivascular  deposit  plainly  indicates  diapedesis,  the 
essential  point  of  agreement  in  all  inflammations.  Some  injury  to  the 
cement-substance  in  the  vessel-walls  sufficient  to  allow  the  egress  of  the 
white  corpuscles  from  the  vessels  has  occurred.  These  elements  have 
been  found  to  assume  the  same  conditions  seen  in  transudation-products 
in  other  organs,  notably  the  liver.  The  hypersecretion  observed  clinic- 
ally in  this  affection  and  the  wide  lymphatic  spaces  of  the  mucosa  sug- 
gest that  these,  lying  patulous  in  the  midst  of  the  transuded  cells  and 
plasma,  are  constantly  busy  in  absorbing  the  infiltration  and  discharging 
a  portion  at  least  into  the  uterine  canal.  The  hypersesthesia  noted  in 
chronic  metritis  is  a  clinical  symptom  of  inflammation.  Martin  of  Ber- 
lin, in  his  textbook  published  in  1885,  describes  chronic  metritis  as  a 
chronic  inflammation  of  the  uterus,  although  admitting  some  slight  dis- 
agreement between  this  process  in  the  uterus  and  chronic  inflammations- 


suJuwdLrrmx  nr  riii:  i-n:i:rs.  649 

c'lscwljcro.  IIl'  :il.s(»  adduces,  as  addilimial  cxidciifi- (if  its  iiillaiMinatorv 
charucter,  the  lac^t  thai  it  is  usually  accumpaiiicd  l)y  iuilauiniation  ol"  the 
nmcosu  juul  serosii  ol"  tln'  ulciiis. 

It  is  a  matter  of  iiuicli  regret  that  alth()u;;li  suhinvolutioii  has  had  a 
more  or  less  disliuct  |»lace  amonj^  uterine  diseases  loi'  over  lorty  ye;irs, 
no  |)atlioloi!;ieal  tc!stiniouy  reoardinjr  the  eondition  (»!"  I  lie  uterus  alfeeted 
with  this  a|)i)areutly  iiei;ative  disease  has  been  oilered.  Its  antecedent 
ste|)  or  condition,  the  histology  of  the  post-i)artum  uterus  durin<^  regres- 
sion, is  I'airlv  understood,  and  th<'  j)atlu)l()<jjical  condition,  chrouie  metri- 
tis, wliicli  is  sometiines  in  some  way  su[H;rinduee(l  or  eiiiiral'ted  upon  it, 
is  now  (|uite  clearlv  demonstrated.  Consequently,  the  real  [)alhology 
t)f  pure  and  simi)le  subinvolution,  a  eondition  holding  a  j)lace  some- 
wheri'  between  the  normal  post-partuni  uterus  and  chronic  metritis,  is 
reduced  to  the  uncertainty  of  inference. 

E'ri()L()(;v. — Considering  the  etiology  of  subinvolution  from  a  patho- 
logical point  of  view,  we  are  yet  more  in  the  dark  than  in  the  pathology 
itself.  A  study  of  the  morbid  anatomy  has  enlightened  us  regarding 
its  existing  conditions  to  some  extent,  but  offers  little  or  nothing  con- 
cerning the  initial  pathological  causes.  Klob'  tells  us  it  is  due  to  a 
"  formative  irritation ;"  which  means  nothing  so  long  as  he  is  unable 
to  t(>ll  us  Avhat  the  irritation  is.  The  word  cause  would  mean  about  as 
nmcli  as  "  irritation  "  in  his  definition.  It  is  a  definition  which  does 
not  define.  He  also  assigns  "  habitual  hyperpemia  "  as  the  cause  of  this 
condition,  which  is  rather  a  result  of  the  ambiguous  "  irritation,"  or  at 
best  a  secondary  cause.  Habitual  hypersemia  undoubtedly  is  the  initial 
stage  of  the  affecti(Mi,  and  thus  stands  in  a  causative  relation  to  the  sec- 
oudarv  stase — infiltration  of  the  walls  with  embrvonic  elements. 

Clinically  examined,  the  etiology  seems  to  be  better  understood,  and 
nearly  all  etiology  classifications  are  clinical  in  character.  As  the  term 
subinvolution  implies,  there  is  an  impeded  or  retarded  involution  after 
parturition  ;  but,  again,  from  our  conclusions  on  the  pathology  of  the 
subject,  the  process  is  not  actual  arrest  of  involution,  but  a  pathological 
process  engrafted  upon  or  coincident  with  uterine  involution.  "  Habit- 
ual hypersemia,"  "  engorgement,"  '' congestion,"  are  recognized  condi- 
tions in  this  malady  at  the  outset,  and  thus,  clinically,  any  cause  lead- 
ing to  such  conditions  is  a  cause  indirectly  for  their  ultimate  result, 
which  we  have  seen  to  be  subinvolution. 

Conditions  leading  to  hypernsmia,  engorgement,  or  congestion  of  the 
uterus  may  be  divided  into  constitutional  or  predisposing  and  exciting 
causes : 

1.  Any  constitutional  state  which  is  characterized  by  non-resistant 
tissues,  as  tuberculosis,  serofulosis.  In  such  women  reconstructive  ])ower 
is  much  lessened,  and  their  ability  to  resist  and  avert  pathological  con- 

'  Op.  cit.,  p.  127. 


650  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

ditions  and  processes  is  defective.  lu  such  a  patient  there  is  a  great 
lack  of  muscular  power  and  nerve-force,„\vhich  is  marked  as  well  in  the 
involuntary  muscles  and  nervous  system  of  the  uterus  as  throughout 
the  voluntary  muscular  and  nervous  apparatus.  Such  are  the  so-called 
albuminous  or  gelatinous  types  of  body,  which  are  characterized  by  a 
low  vitality,  feeble  circulation,  hypersesthesia  of  the  nervous  system, 
ilabbiness  of  the  muscles — which  ordinarily  recover  but  slow^ly  from 
the  eifect  of  parturition,  and  are  liable  to  the  puerperal  maladies,  espe- 
cially such  as  depend  on  the  feeble  and  unhealthy  contractions  of  the 
uterus  after  delivery.  Here  also  the  exhausting  effects  of  lactation  are 
much  more  marked,  and  while,  as  will  be  seen  later,  it  acts  in  healthy 
women  as  a  stimulation  to  the  reduction  of  the  uterus,  in  such  cases  it 
is  such  an  extreme  draft  on  the  vital  powers  as  to  render  the  system  less 
able  to  combat  the  tendency  to  this  pathological  process. 

2.  The  weakening  eifect  of  frequent  deliveries.  No  one  can  doubt 
the  fact  that  cases  of  subinvolution  are  much  more  frequent  in  multi- 
parse,  and  that  the  number  of  cases  increases  with  the  number  of  pre- 
vious parturitions  through  which  the  patients  have  passed.  Klob  says : 
"  Frequently  this  proliferation  of  connective  tissue  is  developed  after 
repeated  deliveries  in  rapid  succession."  Such  being  the  case,  the  cause 
must  be  sought  for  in  habitual  hyjDersemia.  Certainly,  no  supposable 
condition  of  the  uterus  more  nearly  fulfils  the  requirements  of  habitual 
hypereemia,  engorgement,  and  congestion,  noted  as  causal  conditions, 
than  the  gravid  condition  frequently  rejjeatecl.  Under  such  conditions 
the  power  for  complete  muscular  contraction  is  lost :  subinvolution 
becomes  inevitable. 

3.  Blood  dyscrasise,  among  which  may  be  classed  such  constitutions 
as  are  marked  by  ausemia,  which  is  really  one  of  the  sources  of  the 
diminished  vitality  and  want  of  resiliency  in  the  reparative  processes 
which  is  often  among  the  predisjDOsing  causes  of  defective  involution ; 
also,  conditions  of  spansemia  where  the  recuperative  powers  are  lessened 
by  the  loss  of  the  oxygenating  and  repairing  influence  of  the  fewer 
number  of  red  corpuscles. 

Exciting  Causes. — 1.  Of  the  exciting  causes  connected  with  par- 
turition, probably  none  is  more  prolific  in  promotion  of  the  conditions 
leading  to  subinvolution  than  the  pernicious  habit  of  allowing  puerperal 
woman  to  abandon  the  recumbent  posture  too  soon  after  delivery.  It 
is  granted  that  in  this  regard  no  absolute  time  can  be  fixed  as  the  proper 
limit  for  all  cases,  since  it  cannot  be  denied  that  involution  of  the  uterus 
'occurs  in  much  shorter  time  with  some  subjects  than  with  others. 

Notwithstanding  the  discrej^ancy  of  authorities  on  this  point,  it  may 
be  safely  assumed  that  in  most  cases  involution  is  not  complete  under 
six  weeks ;  nevertheless  it  is  in  most  cases  so  far  advanced  at  the  close 
of  the  second  week  that  leaving  the  recumbent  posture  for  short  periods 


sriii.wnij'Trox  or  the  rricnus.  GoI 

ol"  tiiiK'  cacli  tla\-,  with  luodoriite  exeiviso,  will  latlu  r  proiiuttc  than 
I'ctaid  this  procL'ss,  as  such  h  coufso  will  add  to  the  (hccrruliicss  of  the 
j>atii'iit,  c'lismv  a  In'ttcr  atinosjdu'iv,  a  lu-ltcr  (•iiv-ulatioii,  better  appetite 
ami  di<i('stioii.  ( )ii  tlu'  other  hand,  leaxini;  the  reeiiinbeiit  posture  while 
the  veins  are  still  enlari;ed  aiitl  the  uterus  liea\y  with  fat  will  tend 
toward  the  niaintenanee  of  the  venous  congestion  and  defeat  the  absorp- 
tion of  the  fattily-degenerated  uterine  tissue.  Sueli  venous  congestion 
and  iK'Heient  absor|)tion  of  involution-products  are  the  iirst  stei)S  in  tiie 
process  ot"  sul)involiition.  No  canonieal  law  can  be  established  as  t(»  the 
exact  time  for  which  the  recumbent  posture  slionld  l)e  ol>served.  The 
proper  time  varies  with  each  case,  and  must  be  decided  by  the  clinical 
phenomena  in  each  instance.  It  is  a  good  rule  to  keep  the  j)atient  in 
bed  so  long  as  the  lochia  rubra  continue,  as  advocated  by  Lusk.'  The 
(•ontinuance  of  the  lochia  rubra  is  a  clinical  exjiression  of  such  active 
involution  as  is  not  consonant  with  the  uj)right  posture. 

There  is  also  little  doubt  that  involution  is  not  far  enough  advanced 
even  at  this  time  to  permit  getting  up  with  safety.  Fatty  degeneration 
and  absorption  are  not  well  performed  until  after  the  sanguineous 
elements  from  the  uterine  sinuses  have  ceased  to  give  the  red  tinge 
to  the  lochia.  This  fatty  degeneration  and  its  coincident  absorption 
and  discharge  are  not  -vvell  under  way  until  the  lochia  alba  apjjcar. 
Garrigues^  believes  that  involution  is  not  so  well  established  as  to  war- 
rant the  upright  posture  until  the  uterus  has  receded  from  the  anterior 
abdominal  wall  and  again  resumed  its  position  in  the  pelvic  cavity. 

2.  Lacerations  of  the  cervix  uteri  are  among  the  most  important  of 
the  exciting  causes  of  subinvolution.  When  there  is  a  lacerated  tissue 
more  blood  is  required  to  institute  i-epair.  In  the  lacerated  cervix  the 
increased  quantity  of  blood  needed  for  healing  the  breach  answers  the 
great  requirement  in  the  etiology  of  this  condition — engorgement,  venous 
hypera^mia.  As  a  part  of  the  re])arative  ])rocess,  here  as  elsewhere,  we 
have  the  exuded  plasma  recognized  as  essential  to  granulative  repair  in 
soft  ])arts.  Such  transudation-products  are,  by  inference,  a  partial  source 
of  the  uterine  enlargement  in  defective  involution,  and  thus  in  Nature's 
attempt  to  restore  the  broken  continuitv'  Ave  have  for  a  longer  or  shorter 
time  a  literal  local  subinvolution.  Again,  considering  the  fatty  degen- 
eration which  is  taking  place  in  the  uterus  during  involution,  the  process 
of  repair  is  greatly  hindered.  Tissues  in  a  state  of  fattv'  degeneration 
are  not  in  a  favorable  condition  for  union  by  granulation,  nmch  less  for 
union  by  first  intention.  Such  cases  will  always  shoAv  a  tardy  involu- 
tion, and  in  most  cases  a  general  subinvolution  superinduced  upon  the 
local  injury.  AVhen  the  ]>atient  leaves  her  couch,  even  though  long 
after  parturition,  and  involution  is  apparently  conq)lete,  subinvolution 

'  Science  and  Art  of  Midirifenj,  p.  255,  1885. 
^  Am.  Journ.  Ob.-'t.,  vol.  xiii.  p.  861. 


652  SUBINVOLUTION   OF  THE   UTERUS  AND    VAGINA. 

may  be  caused  by  the  weight  of  the  uterus  pressing  apart  the  partially- 
united  lips  of  the  laceration.  This  is  especially  prone  to  occur,  as 
pointed  out  by  Hardon/  where  the  rent  has  extended  through  the 
cro^vn  of  the  cervix  and  the  sides  of  the  tear  are  drawn  apart  by  the 
uterine  supports.  This  deformity  causes  the  uterus  to  sink  downward, 
everts  the  mucous  membrane  of  the  cervical  canal,  and  makes  the  lace- 
rated cervix  to  rest  upon  the  vaginal  pillar.  Xot  only  does  this  posi- 
tion induce  venous  congestion  in  the  whole  organ,  but  the  same  end  is 
fostered  by  the  irritation  of  the  cicatricial  tissue,  which  is  thus  brought 
into  prominence  between  the  separated  lips  of  the  laceration. 

3.  Endometritis  as  a  localized  source  of  engorgement  stands  in  a 
causal  relation  to  subinvolution.  The  purely  inflammatory  form  of 
endometritis,  as  described  by  De  Sinety,  is  probably  chiefly  associated 
with  chronic  metritis,  and  accounts  for  the  clinical  condition  of  excessive 
endometrial  tenderness  wdiich  Jacobi  has  pointed  out  in  chronic  metritis. 
The  glandular  and  fungous  forms  of  endometritis,  as  described  by 
Olshausen  and  Ruge,  are  the  most  frequent  concomitants  of  subinvolu- 
tion. The  exact  relations  of  these  forms  to  subinvolution  has  not  been 
demonstrated,  but  since  many  cases  of  subinvolution  exist  without  coin- 
cident endometritis,  and  neither  glandular  nor  fungous  endometritis  is 
found  without  more  or  less  subinvolution,  it  may  be  inferred  that  the 
disease  w'hich  w^as  primarily  localized  in  the  endometrium  has  led  to 
the  general  engorgement  of  the  whole  uterus  and  a  consequent  sub- 
involution. 

4.  Neoplasms  of  the  uterus  may,  either  by  the  irritation  set  up  in 
their  locality  by  their  presence  or  by  pressure  checking  the  return  floAV 
from  the  uterine  veins,  lead  to  a  congestion  which  shall  be  followed  by 
subinvolution.  Such  is  the  tendency  of  these  growths  even  in  the 
absence  of  parturition,  but  in  the  greatly  enlarged,  valveless,  tortuous 
veins  of  the  gravid  uterus  the  tendency  is  greatly  increased. 

5.  Tumors  above  and  distinct  from  the  uterus  may  so  press  upon  the 
vena  cava  as  to  lead  to  such  mechanical  compression  as  will  increase  the 
tendency  to  venous  congestion  and  subinvolution. 

6.  Chronic  constipation  may  lend  some  aid  to  uterine  congestion  by 
mechanical  compression,  and  thus  enroll  itself  among  the  exciting 
etiological  factors. 

7.  Excessive  sexual  intercourse  has  been  frequently  mentioned  by 
authors  as  leading  to  enlargement  of  the  uterus  in  the  non-puerperal 
state.  This  has  been  chiefly  alluded  to  as  a  cause  for  the  condition 
called  chronic  metritis.  Scanzoni  says^  he  has  seen  the  afi'ection  in 
filles  puhliques.  Now,  if  such  an  habitual  hypersemia  may  be  induced 
in  the  nulliparous  uterus  by  excessive  sexual  intercourse,  how  much 
more  potent  a  factor  might  such  a  practice  be  in  the  recently  impreg- 

^  Am.  Journ.  Obst.,  vol.  xiv.  p.  557.  ^  Op.  cit. 


sriH.WnLCTinX  t,F  Till-:   I'TF.nUS.  653 

ii;it<tl  nrL;:iii,  wIium-  ti»ii«s  ai'c  yt-t  sticciilciii  :iii<l  vessels  oiilar<r«'(| — a 
coiiilitii>ii  iiivitiim  coii^rstioii  ami  tiiliamiiiti  the  >ii><'<|»til)ility  to 
«'ii<;uriii'iii('nt  I 

8.  KctaiiK'il  niriiiln-aiio,  jHti-tioiis  ot"  j)lac<'iita,  nr  (li>tcii~i(iii  i»("  the 
uteriiK'  cavitv  l>v  clots  is  coiiccdeil  to  stand  in  a  causative  relation  to 
tlii^  disease.  Any  lorei^^n  hody,  as  the  al)ov(',  will  exert  a  dist«'ndin<^ 
influence  which  ineclianieally  increases  the  iiody  of  the  nteiiis  and  pre- 
vents the  normal  action  of  the  nuiscniar  walls,  either  of"  which  leaves 
the  vessels  larj^e  and  inll.  Aside  from  the  mechanical  inHncnce  of  such 
bcxlies  in  the  litems,  the  septic  conditions  often  induced  lead  to  a  flahhy 
condition  of  the  origan  conducive  to  enu-or<fement, 

9.  J\)st-partum  hemorrhage  is  i)roi)erly  iissigned  as  a  cause  of  this 
disease.  A.  II.  Simpson  '  has  noticed  that  superinvolution  often  fol- 
lows post-partnm  hemorrhage.  iSueli  a  serpience  is  not  strange  when 
we  consider  superinvolution  a  last  stage  in  the  j)rocess  which  has  sub- 
involution for  its  earlier  condition;  and  those  who  make  post-i»artum 
hemorrhage  a  cause  of  subinvolution,  and  tliose  who  make  it  a  cause 
for  superinvolution,  are  doubtless  both  right,  though  at  ditterent  stages 
in  the  process. 

10.  Abortions  mav  l)e  followed  by  this  disease.  Indeed,  Atthill 
claims,-  and  we  think  Justly,  that  abortions  are  more  likely  to  be  fol- 
lowed by  this  malady  than  delivery  at  full  term.  He  assigns  the  fol- 
lowing reasons  for  this  fact :  The  fatty  degeneration  of  the  uterus  is 
alreadv  under  way  at  the  time  of  delivery  at  term,  and  thus  leads  to  a 
more  rapid  involution  of  the  uterus.  Again,  the  uterus  is  not  so  well 
])rejxired  to  undergo  fatty  degeneration  Avhen  growing  rapidly.  Prob- 
ably reason  for  the  frequency  of  subinvolution  after  abortion  is  also 
found  in  the  fact  that  women  are  prone  to  attach  less  import  to  an 
abortion  than  a  full-time  parturition,  and  by  insufficient  care  and  too 
«arly  getting  up  bring  about  this  disease,  so  that  the  trouble  is  here 
really  to  be  traced  to  exciting  cause  Xo.  1. 

Galabin^  assigns  as  a  reason  for  this  frequency  the  fact  that  the 
uterine  mucous  membrane,  being  unprepared  for  the  separation  of  the 
decidua,  and  often  having  been  previously  diseased,  is  more  apt  to  be 
left  in  an  al)normal  condition  or  with  portions  of  the  placenta  still 
adhering. 

11.  Displacements  of  the  uterus  are  among  the  most  commonly 
assigned  rauses  of  uterine  subinvolution,  l)ut  a  rational  examination 
of  the  subject  will  call  such  causes  in  question.  There  is  probably  no 
subject  in  gynecology  which  has  given  rise  to  keener  controversy  than 
the  etiology  of  displacements.     Xoliody  seems  entirely  clear  on  the  sub- 

'  Trnn.f.  Edinbnrffh  Oh-^f.  .Sbc,  vol.  viii.  p  91. 

^  LoniKe  Atthill, -1/e^/.  Pre.%<  and  Circular,  London,  vol.  xxxiii.  \>.  41. 

3  Midniferii,  p.  341,  1886. 


654  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

ject,  and  everybody  seems  to  have  a  view  remarkably  well  established, 
considerinpj  the  scarcity  of  accurate  investigation. 

The  uterus  is  a  mobile  organ  within  certain  physiological  limits.  It 
is  pressed  downward  by  a  full  meal  and  with  each  inspiration,  and  an 
engorged  rectum  or  distended  bladder  presses  it  forward  or  backward. 
Such  movements,  however,  are  but  temporary,  and  the  removal  of  the 
cause  allows  the  organ  to  return  to  its  normal  position  by  means  of  the 
resiliency  of  its  supports.  It  is  difficult  to  say  just  where  uterine 
movement  ceases  to  be  physiological  and  becomes  pathological ;  but  it 
is  safe  to  assert  that  such  movements  are  never  pathological  until  there 
is  some  permanent  pathological  weakening  in  some  of  the  supports  of 
the  organ,  or  a  pathological  increase  jn  the  weight  of  the  organ  whicli 
leads  in  time  to  a  similar  change  in  its  supports ;  and  only  after  such 
weakening  of  its  supporting  agencies  can  a  displacement  occur  as  a 
pathological  condition.  Thus  the  conclusion  is  reached  that  as  a  very 
general  rule  all  displacements  are  secondary,  and  due  to  some  other 
change  or  process  in  the  pelvic  viscera.  Such  conclusion  at  once 
greatly  decreases  the  importance  of  displacements  as  a  primary  cause 
of  subinvolution.  Subinvolution  is  certainly  more  frequent,  for  in- 
stance, in  a  retroverted  uterus,  but  the  retroversion  is  generally  caused 
by.  subinvolution  or  some  other  previous  pathological  process. 

It  is  more  rational  and  in  accord  with  the  facts  to  consider  displace- 
ments amono;  the  results  of  subinvolution.  When  subinvolution  occurs 
in  an  abnormally  placed  uterus  as  a  result  of  the  change  of  position,  it 
becomes  then  a  cause  for  further  displacement,  though  not  a  primary 
cause,  and  is  one  of  the  class  of  causes  assigned  by  all  writers  which 
increase  the  weight  of  the  organ.  Graily  Hewitt  refers  all  flexions  to 
softness  of  the  uterine  tissue,  which  is  markedly  the  condition  of  the 
organ  in  this  condition,  but  it  is  not  easy  to  suppose  the  flexion  alone  as 
the  cause  of  softness.  In  respect  to  flexions,  Schroeder  finds  the  etiology 
in  retraction  of  the  cervix  by  the  adhesions  of  peritonitis ;  and  Schultz,. 
in  cellulitis  of  the  ligaments,  wliich  produces  cicatricial  contractions  and 
retracts  the  cervix.  Meigs  ^  finds  the  etiology  of  most  versions  in  patho- 
logical lesions  of  the  ligaments.  An  intelligent  appreciation  and  adapta- 
tion of  the  facts  w^ould  seem  to  warrant  the  conclusion  that  displacements 
are  rarely  a  primary  cause  of  subinvolution,  but  oftener  the  result  of 
that  process,  and  that  such  cases  as  are  said  to  be  due  to  displacement 
are  in  reality  due  to  some  antecedent  condition  which  caused  the  dis- 
placement. 

12.  Among  the  causes  which  should  be  assigned  are  those  conditions,, 
generally  inflammatory,  which  have  their  first  pathological  result  in 
some  uterine  displacement,  as  peritonitis,  cellulitis,  lacerated  perineum^ 
rectal  and  vesical  lacerations,  and  fistulse. 

^  Diseases  of  Women,  p.  237,  1859. 


srnixvni.rrioy  nr  riii:  i-Ti:nrs.  655 

13.  Dt'Hciont  al'tc'r-paiiis  liave  Ir-cii  crcdiU'd  with  a  ••aiisil  i-('lati(»ii  to 
this  disease,  but  such  I'datioii  Is  |)r(»l)al)ly  (tidy  iUiieil'ul.  An  (•\li:iii~ti\<' 
oxainiiiatioii  of  tlu-  tiiiu' and  causes  iiiHiiencing  invohition  l)y  Ar.  S<|-- 
did<()tl '  h'ads  hiiii  to  the  eoiiehisioii  that  "  after-pains  are  not  in  any 
wav  necessary  to  invohition/'  Tliis  conchision  was  based  on  his  tiwn 
observations  and  \\\v  c.\i»hination  of  I^azarewitch,-  which  accounts  for 
after-pains  by  siipposinsj;  tliat  "  when  violent  after-j)ains  occur  they  are 
in  many  cases  to  be  considered  as  the  violent  contraction  of  tlie  whole 
womb,  particidarly  of  its  middle  layer,  in  which  run  the  blood-vessels 
and  the  sensitive  nerves:  compression  of  that  middle  layer  is  indicated 
by  the  painfulness  of  some  after-pains."  Such  explanation  does  not 
warrant  the  inference  that  the  absence  of  such  painful  impressions 
indicates  a  tendency  to  engraft  this  new  pathological  process  called 
subinvolution  upon  the  process  of  normal  involution.  Indeed,  it 
seems  fair  to  presume  from  the  above  explanation  that  severe  after- 
pains  are  an  expression  of  a  hypersesthetic,  if  not  of  a  pathological, 
condition  of  the  middle  layer  of  the  uterus,  which  would  rather  indi- 
cate a  susceptibility  or  tendency  to  subinvolution  than  the  reverse. 

Diagnosis. — Subinvolution,  from  the  definition  of  the  term,  presup- 
poses one  partin-ition  or  abortion  at  least,  and  nulliparity  is  the  only  con- 
dition which  would  exclude  this  form  of  enlargement,  although  a  con- 
ilition  practically  identical  may  occur  in  a  uterus  w-hich  has  never  been 
impregnated.  The  diagnosis  here,  as  in  nearly  all  pelvic  and  uterine 
disorders,  cannot  safely  be  made  from  the  subjective  symptoms  alone, 
since  all  are  vague  and  none  in  any  sense  pathognomonic.  Our  con- 
clusions as  to  the  presence  or  al:)sence  of  this  condition  is  based  here,  as 
elsewhere,  upon  a  careful  examination  and  comparison  of  the  symptoms 
and  physical  signs. 

Symptoms. — In  most  cases  the  patient's  own  history  indicates  that 
her  troulile  began  from  a  previous  confinement,  and  that  she  has  never 
been  perfectly  well  since.  AVeakness  of  the  back  is  one  of  the  most 
generally  present  symptoms,  and  often  the  cause  of  the  patient's  seek- 
ing relief  of  her  medical  adviser. 

Leucorrhoea  exists  to  a  degree  depending  chiefly  on  the  extent  of  the 
affection  of  the  endometrium.  The  menstrual  functicMi  is  irregular.  In 
some  cases  there  is  menorrhagia,  in  others  amenorrhnea  exists.  These 
symptoms  indicate  such  a  diseased  state  of  the  endometrium  as  unfits 
it  for  the  proper  reception  and  nourishment  of  the  fructified  ovum,  and 
as  a  consequence  sterility  is  the  rule.  Painful  defecation  often  exists 
from  the  pressure  of  the  fecal  matter  in  the  rectum  upon  the  enlarged 
and  tender  uterus,  while  the  play  of  the  abdominal  muscles  in  the  same 
act  tends  to  the  same  end.  Vesical  tenesmus  may  exist  from  the  pres- 
sure on  the  bladder  or  from  dragging  upon  that  organ  by  the  enlarged 

*  Traruf.  Edinburrjh  Obgt.  &r.,  vol.  iv.  p.  59.  ^  London  Lancet,  Xo.  7,  1S67. 


656  SUBINVOLUTION  OF  THE    UTERUS  AND    VAGINA. 

and  displaced  uterus.  Dyspareunia  is  a  normal  sequence  of  the  irrita- 
tion of  the  engorged  and  hypersesthetic  cervix.  The  menstrual  func- 
tion is  usually  in  a  condition  of  menorrhagia,  or  at  best  the  periods 
are  more  prolonged  and  frequent  than  normal.  Dysmenorrhoea  often 
occurs,  the  resul$pef  the  physiological  engorgement  of  the  already  over- 
sensitive uterus,  ^vmch  leads  to  pain  of  more  or  less  severity.  It  should, 
however,  be  remembered  that  all  symptoms  depending  upon  local  uterine 
tenderness  are  not  so  well  marked  in  subinvolution  as  in  chronic  metritis. 
A  history  of  repeated  abortions  will,  when  many  of  the  above  symp- 
toms are  appended,  always  lead  to  a  suspicion  of  this  disease,  for 
although  this  condition  tends  to  sterility,  yet  when  the  endometrium 
is  not  so  aifected  as  to  preclude  the  possibility  of  the  fertilized  ovum 
being  established  in  the  uterus,  it  is  often  so  diseased  as  to  fail  to  bring 
the  gestation  to  full  term,  and  abortion  or  miscarriage  occurs.  Indeed, 
as  has  been  noticed  in  connection  with  the  etiology,  subinvolution  is 
more  liable  to  follow  an  abortion  than  a  full-term  parturition,  and  thus 
lead  to  subsequent  and  repeated  abortions,  where  it  is  the  result  of  the 
first  and  the  cause  of  those  following. 

There  are  also  certain  other  symptoms  which  at  times  occur  and  tend 
to  increase  the  difficulties  of  diagnosis  by  leading  to  a  suspicion  of  preg- 
nancy. Among  these  are  nausea  arising  from  an  enlarged  uterus  and 
engorged  rectum,  the  darkening  of  the  areolse  about  the  nipples,  and 
pain  and  enlargement  of  the  breasts  from  sympathetic  disturbances. 
Hemorrhoids  are  at  times  a  secondary  result  of  the  slowed  circula- 
tion and  constipation.  Many  and  ill-defined  nervous  disorders  and 
manifestations  are  apt  to  arise,  depending  on  the  temperament  of  the 
patient  and  the  duration  of  the  disease. 

Physical  Signs.— While  the  symptoms  are  vague  and  without 
accurate  diagnostic  significance,  the  physical  signs  are  very  much  more 
valuable,  and  are  the  chief  dependence  in  arriving  at  a  sound  conclu- 
sion as  to  the  presence  or  absence  of  the  disease.  A  vaginal  examina- 
tion in  this  affection  discloses  a  large  boggy  cervix,  often  lower  than 
normal,  Avith  os  patulous,  mucous  membrane  pouting.  Pressure  of  the 
cervix  in  any  direction  by  the  examining  finger  causes  pain,  more 
marked  when  pressure  is  made  in  the  posterior  surface  from  the  poste- 
rior cul-de-sac ;  pain  under  pressure,  however,  is  not  so  severe  as  in 
chronic  metritis.  The  whole  organ,  except  in  cases  where  subinvolu- 
tion involves  the  cervix  alone,  will  be  found  large  and  heavy,  and  as 
a  rule  freely  movable.  Hypersesthesia  of  the  uterus  is  a  frequent  con- 
comitant. 

An  examination  is  also  at  times  followed  by  some  bleeding  from  the 
congested  vessels  of  the  cervix  so  imperfectly  covered  by  the  diseased 
mucous  membrane.  The  speculum  will  bring  into  view  an  enlarged 
cervix,  patulous  os,  and  a  congested,   eroded,   granular,  or  ulcerated 


svnisvoLVTioy  of  tiie  uterus.  667 

(rare)  (•<iii(litiiiii  of  the  niucoii-  iii(iiil)iaiic.  Often  its  an  excitin*^  (siuso 
a  niorr  <>r  Ic.-s  t;aj)iiiir  lac(i"atit»M  is  seoii.  If  the  case  be  of  l<»n<^  stand- 
in<j;  the  field  nt"  the  hiciTation  is  apt  to  be  filled  with  new  tissue. 

Ill  makiiiu-  a  diauiiosis  the  intimate  relation  between  laeeration  of  the 
cvrvix  and  sul)involiition  must  not  be  for<j:;otten.  The  im{)ortauce  of 
laeeration  of  the  i-ervix  as  an  ('tiolo«!:ieal  iactor  has  already  l>ef'U  j)ointe<l 
out  ill  till'  proper  j)lace,  and  here  it  may  l)e  remarked  that  if  a  laeera- 
tion of  the  eervix  is  oi)served,  the  diajxnosis  ot"  m<»re  or  less  subinvolu- 
tion either  of  the  whole  uterus  or  of  the  eervix  alone  is  almost  absolutely 
eertain.  Conjoined  manipulation  discloses  above  the  enlarged  and  dis- 
eased eervix  the  body  of  the  uterus,  enlaro:ed,  more  globidar,  and  less 
])vriform  than  normal,  and  often  disj)laeed.  It'  the  Ijody  of  the  uterus 
is  not  fouml  to  partake  in  the  enlargement,  the  case  is  one  of  cervical 
subinvolution  alone — a  condition  relatively  less  frequent  than  chronic 
inflammation  of  the  cervix. 

Valuable  information  is  to  be  gaine<l  from  the  use  of  the  uterine 
probe  or  s(»iind,  which  will  be  found  to  enter  the  uterine  canal  a  dis- 
tance of  three  and  a  half  inches  or  more,  depending  upon  the  severity 
or  duration  of  the  disease.  It  is  well  here  to  point  out  a  jjossible  source 
of  error  first  mentioned  by  Matthews  Duncan,'  where  the  sound  by 
entering  an  inordinately  patulous  Fallopian  tube  might  indicate  a  much 
greater  depth  than  is  real.  Not  only  does  the  sound  pass  to  a  greater 
depth  tlian  normal,  but  it  is  much  more  freely  movable  at  its  point,  and 
its  introduction  and  manipulation  often  provoke  rather  profuse  hemor- 
rhage from  the  fuugosities  of  the  endometrium. 

DiFFEREXTiATiox. — Since  there  are  some  conditions  Avith  Avhich 
subinvolution  might  readily  be  confounded,  a  few  remarks  on  its  dif- 
ferentiation may  be  useful.     It  has  some  points  of  semblance  to — 

1st.  Pregnancy. — It  may  be  especially  difficult  to  diiferentiate  sub- 
involution from  early  pregnancy  in  lactating  women,  since  the  latter 
may  occur  without  the  recurresice  of  the  catamenia,  and  subinvolution 
at  this  time  does  not  exhibit  itself  in  the  character  of  the  menstruation. 
Under  .such  circumstances  the  only  safe  course  is  to  wait  one  or  two 
months  for  the  development  of  the  usual  signs  of  pregnancy  in  a  sus- 
pected case.  Chief  reliance  must  be  placed  upon  the  progressive 
enlargement  of  the  uterus  in  pregnancy,  whereas  the  enlargement  of 
subinvolution  is  stationary.  The  well-recognized  change  in  the  form 
and  consistency  of  the  uterus,  even  in  the  early  stages  of  pregnancv, 
as  disclosed  by  bimanual  examination,  may  be  of  great  service  in  ar- 
riving at  a  diagnosis,  but  cannot  be  conclusive  earlier  than  the  tenth 
Mcek,  especially  in  fat  subjects.  Where  pregnancy  is  suspected  it  is 
needless  to  say  that  the  sound  as  a  means  of  diagnosis  is  not  to  be 
employed. 

^  Edinburgh  Month.  Journ.,  1S56,  p.  1057. 
Vol.  I. — 42 


658  SUBINVOLUTION   OF  THE    UTERUS  AND    VAGINA. 

2d.  Periuterine  inflammations,  which  are  indeed  amoDg  the  conditions 
leading  to  this  affection,  cause  sensitiveness  to  touch  and  many  symp- 
toms common  to  it,  and  when  suspected  also  preclude  the  possibility  of 
employing  the  sound  with  safety.  Careful  manipulation  will  disclose 
their  localized  tenderness  and  the  asymmetry  of  their  enlargement, 
while  usually  the  cervix  will  be  found  normal  in  size  and  leucorrhoea 
absent.  The  fixedness  of  the  uterus  is  a  very  general  condition  in  these 
inflammations  not  usually  marking  subinvolution.  Such  inflammations, 
too,  give  rise,  as  a  rule,  to  some  systemic  febrile  action  which  in  no  way 
characterizes  subinvolution.  Moreover,  the  history  of  the  case  often 
points  to  the  sudden  inception  of  the  trouble  in  these  inflammations, 
instead  of  the  insidious  beginnings  of  cases  of  subinvolution. 

3d.  Neoplasms  of  various  types  lead  to  enlargement  of  the  uterus. 
The  most  frequent  of  these  are  the  fibromata  and  myo-fibromata.  Such 
tumors  often  produce  dragging  sensations,  pain  in  the  pelvis  and  back, 
leucorrhoea,  menorrhagia,  and  many  constitutional  symptoms  observed 
in  subinvolution.  A  vaginal  examination  usually  shows  a  low  or 
displaced  uterus  increased  in  size.  Where  the  growth  has  attained 
such  size  as  to  cause  the  uterus  to  ascend  out  of  the  pelvic  cavity, 
there  is  no  difficulty  in  diiferentiation.  Careful  conjoined  manipu- 
lation, however,  generally  enables  us  to  make  out  the  chief  differ- 
ential point,  the  unsymmetrical  enlargement  of  the  organ.  The 
growth  in  such  cases  will  usually  be  found  localized  in  one  of  the 
uterine  walls. 

In  confirmation  of  this  localization  the  sound  is  of  much  value. 
There  will  be  little  if  any  tenderness  on  pressure,  and  scarcely  any 
pain  will  be  elicited  by  manipulation.  The  history  will  rarely  date  the 
beginning  of  the  trouble  at  parturition.  The  cervix  in  these  cases  does 
not  often  show  any  enlargement.  Some  cases  there  are  where  the 
enlargement  due  to  a  neoplastic  growth  is  so  symmetrical  as  to  render 
the  diagnosis  very  difficult.  This  is  chiefly  the  case  where  the  growth 
is  intra-uterine  or  submucous.  In  such  cases  mistakes  in  the  recognition 
of  the  true  condition  are  by  no  means  uncommon.  It  is  here  that  the 
dilatation  of  the  cervix  and  the  exploration  of  the  uterine  cavity  by  the 
finger  or  sound  find  the  greatest  field  of  utility. 

A  scirrhous  cancer  of  the  cervix,  with  its  enlargement,  hemorrhage, 
and  other  symptoms,  may  simulate  for  a  short  time  the  condition  of 
subinvolution.  Confusion  is  all  the  more  likely  because  in  the  early 
stage  of  scirrhus  of  the  cervix  there  is  usually  but  little  pain.  The 
history,  the  presence  or  absence  of  cachexia,  metrorrhagia,  etc.,  will 
assist  in  clearing  up  the  obscurity.  The  test  originated  by  Spiegelberg 
is  in  this  instance  a  valuable  means  of  differentiation.  He  introduces 
a  tent  into  the  cervical  canal,  and  if  the  dilatation  is  ready  and  regular 
and  the  cervical  tissue  softens,  the  carcinomatous  character  of  the  aifec- 


sri:iwni.rri().\  of  tui'.  rrr.iirs.  (;:,!! 

tii)ii  is  ruled  i>iil  ;  while  if  llie  e.iiial  (lil:ile>  >lii\\  In,  and  on  diie  sido 
more  tliaii  aiiotlier,  leaxiii^i  llie  eer\i.\  liaid  and  den~e,  iliedi.-ea>e  is 
prc'snnial)Iv  eaneeroiis. 

CoiiriN,'  ill  I  real  iiiL!,' Ill"  I  he  dillrreiiliarniii  orane-icd  insdhil  ion,  savs  : 
"There  art'  two  |)iiiiei|)al  charaeteiMsties  which  will  aid  in  niakinji' a 
(lia«;"n()sis  and  ^listill^'llishin^■  the  arresi  <»!'  in\dliilioii  from  other  kinds 
of  livpertrophv  :  l''irsl,  the  niiilorni  softness  of  the  uterine  ti>.-iie,  eoin- 
hiiied  with  tlie  red  color  and  other  characteristics  of  oeslative  eon^^cs- 
tion  ;  second,  the  extreme  hixity  of  the  lij;uinents,  and  eoiise<|nent  tend- 
ency to  prolapse,  or  at  least  the  indili'erence  of  ])osition  or  direetion  of 
the  uterus." 

4tli.  ( 'Iiroiiic  Metritis  {Arci)l(ir  JIijjjcrjAa.sia). — The  <j;reatest  ditliculty 
will  be  met  in  ditVerentiatin^  subinvolution  from  ehronic  metritis,  since 
in  both  the  svmptoms  and  [)hysieal  sit>;ns  differ  chieHy  in  detiree.  In  siil)- 
involution  the  uterus  is  larger,  softer,  and  less  tender  than  in  cjiroiiie 
metritis,  where,  although  enlarged,  it  is  smaller  and  eompaiativcly  liini. 
In  subinvolution  the  uterine  [)robe  enters  to  a  de])th  of  three  and  a 
half  inehes  or  inore  and  causes  considerable  hemorrhage,  while  in 
ehronic  metritis  it  enters  to  a  depth  only  slightly  greater  than  normal, 
exciting  intense  pain  and  usually  followed  by  less  hemorrhage.  In 
subinvolution  the  endometritis  is  mostlv  of  the  fungous  or  glandular 
variety — hypertro})hy  of  the  endometrium — and  consequently  men- 
struation is  usually  ])rofuse,  but  not  so  painful.  In  chronic  metritis 
the  endometritis  is  generally  of  the  embiyonic  type,  the  mucous  mem- 
brane having  largely  desquamated  and  the  vegetations  consisting  of 
embryonic  tissue  similar  to  the  inflammatory  granulations  Avhich  foi-m 
upon  exposed  wounds.  Menstruation  will  consequently  be  markedly 
painful,  but  not  so  profuse  as  in  subinvolution.  In  subinvolution  the 
heavy,  slightly  sensitive  uterus  produces  dragging  sensations,  but  not 
always  distinct  pain.  In  chronic  metritis  the  inflamed  and  hypersensi- 
tive organ  leads  to  more  or  less  acute  suffering  with  various  irradiated 
pelvic  pains. 

Course  axd  Resui/fs. — As  has  been  indicated  under  Pathology, 
the  tendency  of  this  disease,  untreated  and  nncomj^licated.  is  to  the 
establishment  of  chronic  metritis,  and  later  sclerosis  of  the  uterus,  the 
so-called  snperinvolution.  The  scarcity  of  observed  and  recorded  cases 
of  superinvolution  until  recently  would  indicate  that  the  disease  is  often 
arrested  in  the  state  of  subinvolution  or  in  chronic  metritis,  or  that  the 
condition  of  sujierinvolution  has  escaped  observation.  Botli  these  snp- 
])ositions  are  probably  true,  and  the  great  nundier  of  cases  of  super- 
involution  recorded  recently  evidences  the  truth  of  the  latter,  for  only 
recently  has  the  condition  received  much  attention.  It  is  also  prettv 
well  established  from  abundant  clinical  evidence  that  the  disease  sub- 

'  Op.  cit.,  p.  506. 


660  SUBINVOLUTION   OF  THE   UTERUS  AND    VAGINA. 

involution  is  often  checked^  and  that  treatment  has  often  brought  about 
a  restitutio  ad  integrum. 

As  to  chronic  metritis — which,  according  to  our  belief,  is  one  of  the 
results  of  subinvolution — it  may  be  readily  understood  that  the  source 
of  the  trouble,  proliferation  and  growth  of  embryonic  elements,  may 
be  stopped ;  but  how  these  elements,  when  organized,  may  be  made  to 
disappear  is  not  so  readily  comprehended ;  and  although  clinical  evi- 
dence to  the  fact  in  abundance  is  not  wanting,  yet  we  have  no  micro- 
scopic pathological  investigations  to  attest  it. 

Subinvolution  runs  a  very  slow  course,  as  is  shown  by  the  lapse  of 
time  after  parturition  which  often  occurs  before  it  is  detected.  The 
uterus  is  often  found  to  be  in  this  condition  many  months  or  even  years 
after  a  parturition  or  abortion,  and  the  history  clearly  indicates  the 
beginning  of  the  trouble  at  the  last  confiuement.  Hence  no  approach 
to  definiteness  can  be  attempted  in  describing  the  course  of  subinvolu- 
tion.    Certain  it  is  that  the  course  is  not  uniform. 

Chronic  metritis  is  probably  the  most  frequent  termination  of 
untreated  subinvolution.  Superinvolution  has  been  mentioned,  but 
properly  comes  on  rather  in  cursu  than  as  a  sequel  to  the  chronic 
metritis.  Sterility  often  ensues  from  the  incapability  of  the  endomet- 
rium to  properly  receive  and  nourish  the  fecundated  ovum,  or  abortion 
ensues  from  its  inability  to  maintain  and  support  a  healthy  placenta. 
The  menorrhagia,  pain,  and  attendant  weakness  tend  to  that  chronic 
invalidism  so  often  marked  by  numerous  and  fitful  nervous  symptoms. 
Dysphoria,  occasional  dysmenorrhoea,  dyspareunia,  menorrhagia,  consti- 
pation, vesical  tenesmus,  enumerated  among  the  symptoms,  are  results  of 
this  disease,  any  one  of  which  may  be  sufficiently  aggravated  to  demand 
treatment,  and  indeed  be  the  feature  which  will  lead  the  careful  prac- 
titioner to  a  diagnosis  of  the  underlying  trouble.  Displacements  are 
chiefly  related  to  subinvolution  as  a  result  rather  than  a  cause.  If  a 
small  healthy  uterus,  weighing  a  little  more  than  an  ounce,  is  liable  to 
fall  or  be  drawn  from  its  position,  how  much  more  a  bulky,  cumbrous 
organ  weighing  one  or  two  pounds  ! 

The  atony  of  the  uterine  walls  caused  by  this  condition  of  engorge- 
ment, as  shown  in  a  case  reported  by  Kaschkaroff,  tends  in  the  third 
stage  of  labor  to  retention  of  the  placenta. 

The  probability  of  subinvolution  in  its  late  stages  passing  into  carci- 
noma or  epithelioma  of  the  cervix  has  been  warmly  discussed  pro  and 
con  by  gynecic  writers.  Klob  considers  the  views  of  the  affirmative 
illusory,  and  Thomas  never  saw  a  case.  Noeggerath  has  written  a 
paper  to  prove  that  the  tissue  of  such  a  uterus  tends  to  the  formation 
of  epithelioma,  but  no  other  recent  author,  so  far  as  I  know,  sustains 
his  views.  My  own  clinical  experience  furnishes  several  cases  in  which, 
to  my  own  mind,  the  relation  between  cervical  laceration  and  a  subse- 


sriusvoi.rrios  of  tite  rrEnj\^.  g61 

(|ll('lltly  i|('\('lii|tc(|  cpillicliDiii;!  Wd-f  iiiiii|ili\  ncil,  lull  I  Ii;iv<'  iicvf'i'  seen 
a  sin<;"li'  case  of  cpilliclioiiia  wliitli   I   llniimlil  due  Id  >iiliiii\(i|iiti<iii. 

Ti:i:A'i'.Mi:N'r. —  It  is  <i,iTaily  t<i  the  ric<li(  of  Sii- .lamo  Siniji.-on  that 
tho  methods  of  trcatiiniil  riii|)|o\  cd  l)\-  liim  inniKdiatcIv  on  tlic  disrov- 
(TV  of  the  disease  arc  ii-cil  at  the  pivsciit  lime,  aii<l  that  hut  t"e\v  addi- 
tions to  the  therapeutic  uica>in'c>  inaugurated  l»y  him  have,"  heen  made. 
It  is  rather  strauiie  that  while  he  believed  the  disease  iiiHammatorv  in 
character,  and  addressed  his  ti-eatnient  accord injijly,  nearly  all  ^•yiHioolo- 
ijists  since  have  rejected  his  \ic\\s  as  to  the  cause,  hut  retain  his  inethods 
and  means  of  treatment,  includiuii- <>eneral  as  well  as  local  agents. 

Thomas'  does  not  call  the  tliseixse  inflammation,  hut  he  says:  "  Do  I 
myself  not  hlistci-,  ;i|)ply  leeches, and  even  am[)utate  the  cervix  in  these 
cases?  I  blister  lii^htly  to  exert  an  alterative  influence  on  the  nerves 
for  the  relief  of  coincident  congestion.  I  blister  occasionally  as  I 
would  for  hyperajmia  elsewhere,  and  I  amputate  as  I  would  for  enlarged 
tonsils."  80  woidd  Sir  James  Simpson,  .Scanzoni,  Henry  Bennett,  and 
Chomel ;  and  they  considered  it  an  inflammation,  and  indeed  treated 
other  inflammations  in  the  same  way.  Here  as  elsewhere  we  encounter 
that  incomj)rehensible  "  inflammation,"  which  seems  a  veritable  patho- 
logical chameleon,  taking  its  color  peculiarly  and  faithfully  from  the 
tissue  wherein  it  rests — now  forming  the  plastic  bands  of  pleuritis,  now 
the  white  opacity  of  keratitis,  now  the  pus  of  cellulitis,  and  again  the 
fibrous  bands  of  hepatitis,  and  so  on  ad  infinitum. 

All  treatment  hjoking  to  the  cure  and  cheek  of  this  disease  is,  by  the 
agreement  of  most  authors,  addressed  to  the  congestion  or  engorgement 
of  the  uterus.  This  is  admitted  to  be  an  underlying  condition  indi- 
cating the  course  of  treatment,  and  being  at  the  same  time  its  object. 

For  convenience  the  treatment  is  divided  into  prophylactic  and 
curative. 

Prophylaxis  comprehends  such  measures  as  tend  to  prevent  the  occur- 
rence of  the  diseased  condition.  In  this  interest  labor  should  not  be 
allowed  to  last  so  long,  when  it  can  be  safely  shortened,  as  to  greatlv 
weaken  the  recuperative  powers  of  the  system  or  bruise  the  parts  into 
a  congested  condition,  since  debility  leads  to  feeble  uterine  contractions 
after  labor,  and  thus  to  deficient  expulsion  of  blood  from  the  Avails  of 
the  organ  and  contraction  of  its  vessels.  The  engorgement  and  atonv 
of  the  j)arts  from  prolonged  pressure  and  contusion  are  literally  a  begin- 
ning of  the  disease  which  an  enfeebled  general  condition  may  be  unable 
to  thwart. 

When  conditions  demand  it,  therefore,  partial  anaesthesia  with  forceps 
delivery  should  be  ado])ted.  Zealous  care  and  skill  should  ]»revent  as 
nearly  as  possible  laceration  of  the  cervix  and  pcrineiun,  among  Avhose 
numerous  sequelae  subinvolution  very  often  occurs.     In  short,  everj- 

'  Loc.  cit.,  p.  317. 


662  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

thing  which  obstetric  science  and  skill  can  afford  for  securing  safe  and 
easy  delivery  should  be  employed.     The  binder  is  a  useful  means  of 
promoting  and  maintaining  uterine  contraction,  but  if  too  tightly  applied 
may  cause  retroversion  of  the  yet  engorged  uterus,  and  thus  indeed  per- 
manence of  engorgement  or  subinvolution.     The  patient  should  not  be 
allowed  to  maintain  pelvic  congestion  by  leaving  the  lying-in  couch  too 
soon,  neither  should  she  defer  proper  exercise  so  long  as  to  discourage  a 
healthy  pelvic  circulation.     After  the  fifth  day  she  should  move  about 
in  bed  and  change  posture  frequently — change  from  dorsal  to  lateral 
decubitus.     Constipation  will  engorge  the  local  pelvic  circulation,  and 
its  attendant  tenesmus  in  defecation  will  aggravate  the  same  condition, 
and  also  cause  too  great  a  pressure  on  the  enlarged  uterus,  and  should 
be  avoided  by  the  proper  methods.     The  use  of  ergot  for  some  days 
after  delivery  to  assist  in  securing  and  maintaining  suitable  uterine  con- 
tractions is  generally  approved.     Quinine  is  also  advised  for  the  same 
purpose.     While  much  injury  is  often  done  and  this  disease  established 
by  too  early  rising  from  the  parturient  couch,  there  is  no  doubt  that  the 
opposite  extreme  is  productive  of  evil  consequences.     After  the  proper 
time  (see  remarks  on  Etiology)  has  elapsed,  and  the  patient  has  had  no 
contraindicating  symptoms,  cautious  and  healthful  exercise  should  be 
advised  to  secure  vigorous  action  of  the  general  circulation  and  promote 
tissue-change,  with  removal  of  waste  material  and  a  consequent  demand 
for  food.     There  is  little  doubt  that  the  prevalence  of  subinvolution 
and  other  pelvic  diseases  may  be  partly  traced  to  the  indolent  life  led  by 
so  many  women  in  the  wealthy  classes.     Sexual  intercourse  among  such 
is  in  no  way  abridged  to  concert  with  their  general  inactivity,  and  this, 
with  the  monthly  engorgement  of  the  uterus  by  the  catamenia,  leads  to 
a  pelvic  congestion  entirely  out  of  proportion  with  the  enfeebled  general 
circulation  due  to  aimless  indolence.     Better  rules  as  to  exercise,  with 
moderation  in  sexual  indulgence,  should  be  enjoined.     Galabin  ascribes 
much  of  pelvic  congestion  and  its  kindred  ills  to  our  modern  sumptuous 
upholstery,   which   conduces  to   this  condition  by  making  the  pelvis 
assume  too  low  a  position  when  sitting. 

Retention  of  parts  of  placenta,  membranes,  or  clots  should  be 
avoided  as  an  important  preventive  measure.  It  is  especially  import- 
ant to  guard  against  placental  adhesions  and  retention,  when  we  remem- 
ber, as  has  been  pointed  out  by  Mary  Putnam  Jacobi,  that  the  point 
of  adhesion  or  the  irritation  produced  by  a  portion  of  retained  placenta 
may  prove  the  site  of  a  localized  subinvolution.  This  localization  of 
the  disease  tends  to  induce  general  subinvolution  of  the  whole  uterus. 

Antiseptic  lotions  and  vaginal  injections,  as  prophylactic  to  puerperal 
diseases  when  indicated  by  special  symptoms,  will  also  be  useful  in  pre- 
venting subinvolution,  since  such  diseases  often  pave  the  way  for  this 
condition.     Since  subinvolution  of  the  uterus  is  a  disease  of  raalnutri- 


sri:i.\\(>i.rri(>.\  or  riii:  rii:i:rs.  m:\ 

tioii,  allliDiiLih  |)('i'li:i|)s  ti(  iicrallv  (lc|)('ii(liiit  upon  local  ('aiiscs,  llicrc  can 
l)('  IK)  (|iicstioii  thai  it  is  not  un(Vc(|iicnti\' (lie  rc-nll  of  ocncrallv  lowered 
vitality,  an  en  feel)  led  state  oj"  the  m(.|||.|-;i1  hcalt  li,  to  w  hidi  certain  w  unien 
arc  |»articiilarly  prone  alter  each  partnrition.  (  arefnl  attention  slionid 
tliercloiH'  l)c  <;i\'en  lo  (he  u'eneral  health  and  proper  conslil  ntional  meas- 
ures enip|o\t(l.  l'!.-pecial  care  is  to  lie  enjoined  ill  WOliieii  -iilijcct  to 
al)(>rtioiis  ;  which,  I ly  t lie  w  ay,  ill  I  lew  ill ">  opinion,  iiieaii>  w  omen  alll'dcd 
with  uterine  llexions. 

C'uratix'c  treatment  is  thai  applii'd  lo  the  di>ea>e  when  it  is  foiind 
atK'ctinii;  the  uterus,  and  is  chielly  addressed,  as  has  been  said,  to  tla; 
I'liH-orii-emeut  of"  tlie  uterus.  It  cudjraws  means,  niechanical  or  thera- 
peutical, whose  near  or  remote  effect  is  the  decrease  in  tiie  ainoiini  ol' 
blood  in  the  uterine  tissue.  For  the  sake  of  clearness  it  is  well  to 
divide  these  means  into  eoustitutional  and  local. 

Constitutional  treatiiieiit  is  liere,  as  in  most  pelvic  diseases,  of  <i-reat 
imj)()rtanet'  at  all  times,  hut  the  deg-ree  of  its  importance  ^vill  dejieiid 
largely  upon  the  eoudition  of  each  patient.  A  ease  of  subinvolution 
in  a  healthy  woman,  due,  for  instance,  to  laceration  of  the  cervix,  will 
not  tiemanil  mueii  if  any  attention  to  the  general  health,  while  in  u 
weak,  nervous  woman  with  flabby,  non-resistant  tissues  it  becomes  of 
paramount  importance,  and  is  much  more  conducive  to  cure  than  is 
local  treatment. 

First  among  the  agents  for  coustitutiontd  therapy  are  mineral  and 
vegetable  tonics.  Among  these  iron  is  especially  indicated  where  there 
is  antemia,  and  menorrhagia  is  not  an  important  symptom.  Mercury  in 
the  form  of  the  bichloride  is  recommended  in  small  doses  over  a  lono; 
period  for  its  tonic  effect.  The  mild  chloride  is  also  of  great  value. 
The  salts  of  iodine  and  bromine  are  very  generally  used  by  gynecol- 
ogists. The  iodide  of  potassium  is  indicated  where  there  is  an  indica- 
tion for  promoting  the  absorbent  system,  while  the  bromide  of  potassium 
is  supposed  to  have  an  especial  field  of  usefulness  where  it  is  desirable 
to  diminish  the  functional  activity  of  the  uterus. 

Scanzoni  recommended  hip-baths  containing  combinations  of  bromine 
and  iodine,  with  vaginal  injections  of  a  similar  character.  .Vrscnic  is 
given  as  a  stomach  tonic  here  as  in  other  diseases  where  such  remedies 
are  indicated.  Strychnia  is  much  used  from  its  supposed  ability  to 
impart  muscular  tone  to  the  abdominal  and  ]>clvic  viscera.  Ergot  is 
reconimcndcd  for  its  action  on  unstriped  muscular  tissue.  Theoret- 
ically, it  ought  to  do  good,  but  after  repeated  trial  I  have  but  little  con- 
fidence in  it  for  these  cases.  Quinia  is  given  as  a  bitter  tonic  to  "l)ring 
about  a  better  state  of  the  mucous  membrane  of  the  stomach,  whatever 
that  may  include"  (Xiekles),  and  thus  increase  the  demand  for  food 
and  the  assimilation  of  it.  The  mineral  acids  arc  chiefly  indicated  from 
the  stomach  symptoms,  and  thus  are  used  as  tonics  to  increase  the  gen- 


664  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

eral  nutrition  of  the  body.  When  the  general  nutrition  is  poor  and 
little  food  is  taken  or  assimilated,  cod-liver  oil  plays  a  useful  role,  act- 
ing both  as  a  food  and  as  a  tonic,  leading  to  an  increased  demand  and 
absorption  of  other  food.  The  various  mineral  waters  are  recommended 
for  use  in  their  proper  spheres,  and  baths  of  the  same  character  are  of 
utility  in  this  disease  by  building  uj)  the  general  health.  The  writer 
has  witnessed  decided  benefit  from  cold  sponging  of  the  entire  body 
every  morning  before  the  patient  dresses.  In  most  cases  it  is  better 
that  the  patient  use  the  sponge  without  an  assistant.  Hewitt  thinks 
that  the  waters  at  Kreuznach  have  a  special  adaptation  in  the  bromides 
and  iodides  they  contain.  The  same  kind  of  waters  are  found  at  the 
Triton  and  Union  Springs,  Saratoga. 

It  is  probable,  however,  that  the  chief  benefits  obtained  from  such 
waters  consist  in  the  change  and  rest  for  those  who  perform  household 
duties,  and  activity  for  those  who  lead  lives  of  idleness  at  home.  More- 
over, absence  from  home  avoids  sexual  excesses,  of  so  much  injury  in 
these  cases. ' 

Local  treatment  is  divided  into  therapeutical  and  operative. 

1st.  Therafpeutical. — The  therapeutic  agents  employed  are  mostly 
irritants  or  caustics,  and  are  either  alterative,  stimulant,  or  absorbent 
in  their  effects.  The  cervix  may  be  painted  with  iodine  to  secure  the 
alterative  and  absorbent  effect  of  that  drug.  When  the  fundus  of  the 
uterus  reaches  above  the  pelvic  brim,  Scanzoni  suggests  painting  the 
abdomen  with  tincture  of  iodine.  Collodion  and  acetic  acid  for  its 
blistering  effect  on  the  cervix,  as  employed  by  Aran,  is  highly  recom- 
mended b\'  Thomas,  who  uses  it  by  applying  several  coats  to  the  cervix 
at  stated  intervals.  It  is  followed  in  ten  or  twelve  hours  by  a  free  dis- 
charge of  serum,  which  has  the  desired  depleting  effect  on  the  engorged 
organ.  Scanzoni  also  employs  for  counter-irritation  iodide  of  potassium 
and  glycerin.  Simpson  applied  to  the  uterine  canal,  with  his  sound 
wrapped  with  cotton,  various  irritants  and  caustics.  Nitrate  of  silver 
has  been  extensively  used  within  the  uterine  cavity  in  these  cases,  and 
has  been  followed  by  very  satisfactory  results.  Carbolic  acid,  combined 
with  tincture  of  iodine,  applied  to  the  interior  of  the  uterus,  now  has 
greater  favor  among  gynecic  practitioners  than  any  other  agent.  It 
goes  without  saying  that  medication  of  the  interior  of  the  uterus  is 
not  to  be  attempted  unless  the  canal  is  sufficiently  large  to  permit  a 
return  flow  and  free  discharge. 

For  severe  cases  Lombe  Atthill^  carries  ten  grains  of  ciystallized 
nitrate  of  silver  into  the  uterus,  and  lets  it  dissolve  in  the  cavity.  The 
same  plan  was  carried  out  by  Sir  J.  Simpson.  In  milder  cases  solutions 
of  tannic  or  gallic  acid  may  be  applied  to  the  interior  of  the  uterine 
canal.     Courty  suggests  that  we  may  provoke  the  uterus  to  hypertrophy 

^  Diseases  Peculiar  to  Women,  p.  83  ei  seq. 


si'JU.\V')LCTi'K\  OF  Tin:  riFiirs.  Ofj-j 

l)V  means  of  local  trcatiiiciit,  and  tlicn  take  advantage  <)("  tin-  tiiiilcncv 
ot"  [lie  (»r«;an  l<>  nnih-i'LiK  fatty  dcuencratiftn  and  involntion. 

To  tlie  };i"annlar  ero>ion  of  the  {ci-n  i.\  wliidi  is  oiten  seen  in  llii> 
disease,  and  to  nleeration,  rarely  seen,  various  means  of  aj)j>lieatioii  are 
in  vo;jjiie.  Vaginal  injections  of  hot  water  at  a  temperatni'e  of  Irom 
100°  to  110°  F.  prove  \'eiy  \aUial)le  in  ijic  treatment  of  tlii>  condition. 
To  he  availal)le,  however,  the  nuilioil  is  important,  'i  he  injection 
sh(»idd  i)e  _i;iven  with  the  patient  in  the  recnml)ent  postm-e,  with  the 
buttocks  l)roui:;ht  to  the  eilge  of  tlu;  bed,  and  so  placed  that  the  outHow 
will  wet  neither  her  clothinjj;-  nor  the  beddin*^.  At  least  three  i;alIons 
of  water  shoukl  be  used  at  each  session.  A  fountain  made  by  ase  of  a 
wooden  bucket  and  hose  with  faucet  w  ill  answer  every  purpose.  The 
stream  should  not  be  lari:;e.  The  patient  should  invariably  remain  in 
bed  for  at  least  an  hour  after  the  irrigatiou.  Indeed,  it  would  be  better 
that  it  be  giveu  at  bedtime,  so  that  she  can  remain  in  betl  for  the  night. 
This  treatment  should  be  employed  once  daily.  In  cases  where  vaginal 
})acking  is  employed  it  is  good  [>ractice  to  place  the  packing  in  the  morn- 
ing before  the  patient  arises  from  bed,  allow  it  to  remain  during  the 
day,  and  its  removal  at  night  to  be  followed  by  the  vaginal  irrigation. 
To  Emmet  will  the  profession  be  ever  indebted  for  the  emphasis  he  has 
given  to  the  use  of  hot  water  in  treating  pelvic  congestions  and  inflam- 
mations. Anhydrous  glycerin  in  pledgets  of  cotton  applied  to  the  cervix 
will,  by  abstracting  water,  greatly  deplete  the  over-full  vessels.  Glycerin 
with  tannin  or  boric  acid  makes  one  of  the  most  useful  local  applica- 
tions, combining  the  dehydrating  influence  of  the  glycerin  with  the 
astringent  power  of  the  acid.  The  vagina  should  be  thoroughly 
packed,  especial  care  being  taken  to  fill  all  the  culs-de-sac. 

A\'heu  the  cervix  is  much  ulcerated  or  decidedly  granular  the  caus- 
tics are  generally  used.  Ulceration,  however,  is  extremely  rare.  Xitrate 
of  silver,  caustic  potash,  potassa  cum  calce,  or  chromic  or  nitric  acid 
may  be  applied  according  to  the  severity-  of  the  case,  A  general  observ- 
ance of  the  rule,  to  begin  with  the  milder  and  use  the  stronger  caustics 
later,  if  necessaiy,  is  the  best  method  of  practice.  In  these  cases,  as  in 
all  others,  should  nitrate  of  silver  be  employed,  its  well-known  tendency 
to  harden  and  cicatrize  the  mucous  membrane  of  the  cervix  and  con- 
tract the  OS  must  be  cautiously  guarded  against.  Xo  local  applic-ation 
will  so  speedily  cure  non-specific  erosion  or  ulceration  as  the  solid  nitrate 
of  silver.  But  the  conditions  of  induration,  cicatrization,  and  contrac- 
tion resulting  from  its  indiscriminate  use  are  deplorable,  all  the  more  so 
because  incurable. 

The  importance  of  electricity  as  a  means  of  therajw  in  this  disease  is 
at  last  well  established.  In  simple  subinvolution  the  faradic  current  is 
to  be  emj^loyed  alternately  with  the  g-alvanic.  In  such  cases  "  both  the 
muscular  and  vascular  elements  require  contracting,  and  the  circulation 


666  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

needs  stimulation  in  order  to  hasten  the  normal  retrograde  metamor- 
phosis. Therefore  the  faradic  current  is  especially  indicated."  ^  When 
the  disease  has  passed  into  the  second  or  inflammatory  stage,  chronic 
metritis,  electrolysis  is  indicated  by  means  of  the  galvanic  current." 
The  writer  has  had  frequent  opportunity  of  testing  the  value  of  this 
method  of  treatment. 

Mechanical  Treatment. — When  there  is  displacement  aggravating  the 
disease  the  first  step  in  treatment  will  always  be  its  correction  by  the 
proper  manipulation  and  support  by  pessary  or  other  device. 

Local  therapy  is  nearly  useless  when  a  marked  version  or  flexion 
exists  which  leads  to  a  bending  and  compression  of  the  vessels  so  as  to 
keep  up  the  engorgement.  When  a  pessary  cannot  be  borne  the  patient 
should  rest  in  a  suitable  position  as  much  as  possible,  while  local  treat- 
ment is  addressed  to  the  engorgement  and  its  consequent  tenderness. 
Tampons  of  cotton  saturated  with  tanno-  or  boro-glyceride,  so  placed  as 
to  assist  in  correcting  the  displacement,  will  also,  by  their  dehydrating 
and  astringent  influence  at  the  same  time,  reduce  congestion.  Heavy 
or  tight  clothing  always  tends  to  aggravate  displacements  and  should  be 
avoided.  The  corset  should  be  worn  very  loose,  or,  better,  entirely 
abandoned,  while  skirt-supporters  should  transfer  the  weight  of  the 
skirts  from  the  waist  to  the  shoulders. 

Operative  Treatment. — When  the  cervix  is  large,  tense,  and  congested, 
scarification  or  the  application  of  leeches  is  advised  by  all  authors,  though 
now  very  rarely  resorted  to  in  actual  practice — not  because  it  is  an  irra- 
tional means  of  depletion,  but  because  it  is  not  fashionable.  Depletion 
is  the  manifest  object  of  all  treatment,  and  certainly  no  means  is  a  purer 
depletion  than  this.  We  have  already  expressed  the  belief  that  lacera- 
tion of  the  cervix  is  the  most  common  cause  of  subinvolution.  When- 
ever, therefore,  this  condition  of  the  cervix  is  found,  it  should  be  removed 
by  trachelorrhaphy  at  the  earliest  practicable  moment.  The  influence 
of  the  operation  upon  subinvolution  is  frequently  very  striking.  The 
writer  has  noted  many  cases  where  not  only  the  subinvoluted  uterus 
and  cervix  have  been  reduced  to  normal  size  and  form  within  a  few 
months,  but  the  so-called  reflex  nervous  symptoms,  together  with 
uterine  catarrh,  metrorrhagia,  etc.,  have  vanished. 

In  this  connection  it  is  proper  to  state  that  it  has  been  for  many  years 
the  writer's  custom,  should  metrorrhagia,  menorrhagia,  or  even  marked 
uterine  catarrh  coexist  with  laceration  of  the  cervix,  to  use  the  blunt- 
wire  curette  immediately  preceding  the  trachelorrhaphy,  usually  after 
the  patient  has  been  anaesthetized  for  this  operation.  There  can  be  no 
question  that  the  influence  of  this  procedure  should  be  considered  as 
partly  promoting  the  highly  satisfactory''  results  above  referred  to ;  all, 

1  MuBde,  Am.  Journ.  Obst,  1885,  p.  1252. 

^  Franklin  H.  Martin,  Journ.  Am.  Med.  Assoc,  1886,  vol.  vii.  p.  67. 


scni.woi.rrioy  of  thi:  r.i^/.v.i.  607 

tliorcfbrc,  should  not  he  ;illi"il)Uti'«l  t»»  the  li:i<'li(l<iiili:i|)|iy.  The  wi-itcr 
has  ill  aiintlicr  piihlicalinn  '  expressed  ilie  opiiiioii,  luuiided  upon  a  l:ir;:;e 
elinieal  experience,  lliat  in  a  ease  where  eiirettinii  is  indicated  it  inav  l»e 
done  at  the  same  sittiii}^  with  tiachelorrhaj>hy  without  in  an\'  dcjj;ree 
increasing-  its  I'isks.  This  ininninitv  iVoiii  daiiLicr  iiia\'  l»i'  parlK'  <hie  to 
the  deph'tion  iVoni  trachelorrhaphy. 

\\  (•  inn>t  not  he  understood  lus  rccoinnieiidin^-  the  curette  on  I  v  in 
cases  where  a  (U'^ree  of  hicerati(»n  of  the  cervix  I'xists  (U'inandinj;  tra- 
eliehtrrhaphy.  The  use  ol"  the  etirctte  is  jnstitied  wliero  there  is  exten- 
sive tk'ii'eneratinii  of  the  eiidoiiictriiini  a>  c\iiice(I  l)v  inctrori'hagia, 
inenorrhaiiia,  or  uterine  catarrh.  ( )l'ten  tlie  ch-ansiii!:;  (»f  the  en(h)niet- 
rinin  hv  the  removal  of  villous  or  t"un<z:<>i<l  <i'rowths,  and  the  eonse(pient 
irritation  set  ii])  l)y  such  an  opei-ation,  will  had  loan  active  process  in 
the  uterus  which  soon  eifects  a  cure  of  the  underlyiuu-  suhinvcjlution. 

The  practice  of  ami)Utatinn-  the  cervix  in  suiiinvolution  and  chronic 
metritis,  as  extensively  followed  in  (ici-many  and  to  a  limited  extent  in 
this  country,  is  to  he  mentioned  only  to  he  condemned.  We  fnllv 
eiiiUn'se  the  foUowing  language  of  Dr.  Egbert  PI.  Grandin  :  "  \\C  have 
yet  to  see  the  ease  of  subinvolution  where  amputation  of  the  cer\ix  for 
the  sole  purpose  of  diminishing  the  size  of  the  Ixxlv  was  in  the  least 
called  for."'  This  practice  is  also  condemned  in  the  .strongest  possible 
language  by  Emmet. 

During  the  past  eight  years,  both  in  hosj)ital  and  private  practice,  the 
writer  has  demonstrated  the  value  of  removing  a  wedge-shaped  piece 
from  the  cervix  and  closing  the  rent  with  sutures,  as  in  trachelorrhaphv, 
both  in  sul)involutioii  and  chronic  metritis  (areolar  hy])erplasia\  when 
laceration  of  the  cervix  did  not  exist.  If  a  sufficient  amount  of  tissue 
be  removed  and  the  sutures  properly  introduced,  the  results  are  fre- 
quently quite  satisfactory.  I  always  allow  the  incised  surfaces  to  bleed 
freely  before  placing  them  in  apposition,  in  order  to  produce  as  much 
depletion  as  possible.  This  practice  is  strongly  commended  bv 
Grandin.^ 

An  ingenious  modification  of  this  procedure,  by  which  the  same  end 
is  securefl  without  incision  of  the  vagiiial  mucous  membrane  of  the 
cervix,  is  practised  by  Dr.  Ellwood  Wilson  of  Philadelphia. 

Subinvolution  of  the  Vagina. 

Subinvolution  of  the  vagina  is  that  condition  of  the  organ  when 
post-partum  regression  has  failed  and  the  canal  remains  much  larger, 
more  flabby,  and  less  contractile  than  normal. 

NoMENCLATT'RE. — This  condition  as  an  entitv  has  no  literature.     It 

>  Tmm.  Am.  ^M.  .Ix.sor.,  188-1. 

*  Review  "  Handbuch  der  Frauenkrankheiten,"  Am.  Journ.  Obst.,  July,  1886. 

^  Loc.  cit. 


668  SUBINVOLUTION   OF  THE    UTERUS  AND    VAGINA. 

has  had  but  little  recognition  as  an  underlying  or  complicating  condi- 
tion in  the  affections  of  the  vagina  following  and  incident  to  partu- 
rition. Such  treatment  as  it  has  received  at  the  hands  of  writers  has 
been  directed  to  those  accidental  deformities  which  are  either  the  causes 
or  the  results  of  subinvolution  of  the  vagina.  Accordingly,  it  has  been 
called  "  rectocele  "  when  the  posterior  vaginal  walls  became  unduly  lax 
and  pouted  at  the  vulva.  If  that  part  of  the  vagina  forming  the  floor 
of  Douglas's  pouch  gives  way  and  the  intestines  descend  into  the  sag- 
ging pouch,  it  is  called  an  "  enterocele."  When  the  anterior  wall  gives 
way  through  lack  of  tonicity  and  support  and  presents  at  the  vulvar 
cleft,  it  is  called  a  "  cystocele."  When  the  M'hole  canal  is  in  a  condi- 
tion of  ectropion  it  is  termed  '^  prolapsus  vaginee."  When  the  exciting 
cause  is  in  the  descent  of  the  uterus  through  the  lax  and  patulous  vagi- 
nal canal,  the  resulting  condition  of  the  vagina  has  been  at  times  called 
"  inversion." 

In  whatever  part  of  the  organ  the  weakness  of  the  canal  is  most 
evident,  as  manifested  by  the  deformity  which  gives  a  name  to  the 
disease,  the  underlying  pathological  condition  is  subinvolution  of  the 
vagina. 

In  addition  to  these  expressions  of  the  locus  minoris  resistentice,  there 
are. found  cases  where  the  whole  canal  is  loose,  flabby,  and  patulous,  with 
marked  absence  of  normal  tonicity,  following  a  parturition,  and  usually 
associated  with  subinvolution  of  the  cervix  or  uterus,  or  both.  These 
cases  are  frequent.  They  have  usually  received  no  name,  but  are  cer- 
tainly typical  examples  of  subinvolution  of  the  vagina.  Indeed,  these 
are  the  cases  generally  overlooked  in  the  search  for  or  treatment  of 
uterine  disease.  Most  frequently  the  patient  either  does  not  realize 
the  condition,  or  neglects  it  until  the  condition  declares  itself  more 
distinctly  in  the  form  of  cystocele,  rectocele,  or  prolapsus  vaginae. 

Pathology. — The  vagina  partakes  in  great  degree  in  the  changes 
which  prepare  the  reproductive  organs  for  parturition.  Its  muscular 
tissue  is  largely  increased  by  a  physiological  hypertrophy.  Its  blood- 
supply  is  largely  increased,  as  shown  by  the  change  in  color  which 
occurs  during  pregnancy.  The  marked  fulness  of  the  circulation  is 
also  shown  in  the  "  vaginal  pulse  "  mentioned  as  a  sign  of  pregnancy, 
also  distinctly  recognized  during  attacks  of  acute  cellulitis.  The  va- 
ginal papillae  become  engorged  and  enlarged  as  a  result  of  the  nutrient 
activity  in  the  organ,  and  at  times  a  papillary  vaginitis  is  lighted  up, 
possibly  from  the  venous  congestion  which  ensues  from  pressure  in 
later  gestation.  Also,  the  connective  tissue  is  increased  in  quantity 
and  its  lymph-spaces  are  enlarged  and  engorged,  making  the  whole 
organ  softer  and  more  distensible.  In  the  last  weeks  of  pregnancy 
the  congestion  renders  the  whole  canal  oedematous  and  stimulates  the 
mucous  follicles  to  increased  secretion.     This  secretion  is  sometimes  so 


sr/.'/.vrn/. /'vvo.v  or  riii:  r.u./.v.i.  GG9 

in-ol'iix'    tlint    ill.'    |i:iti(iil,    if  >lic    liiis    licai'd    the    I nidilioii,   savs  slie   is 
losiiiii'    her    milk. 

The  siil)iMiicniis  areolar  tissue  heeomes  es|)eeiallv  a'doiualous,  and  at 
times  the  «edeina  so  diiiiiiiislies  its  tonicity  that  the  deseeiidinj;-  heail 
|)iishes  the  iiiiieoiis  iiieiiihraiie  in  front  of  it  dnrln::-  lalior  l)\-  de-irovin^- 
tile  areolar  altaehnu'iit  hetween  the  Jiiiieoiis  nienihrane  and  the  siihja- 
eent  stnietiires.  WJien  such  an  accident  occurs  siibiiivoliilirtn  is  almost 
cortain  to  follow.  It  is  |»roi)al)ly  ti'ue  that  this  injury  is  rarely  detected 
at  the  tiuie  of  its  occurrence. 

DiH'iuij;  j)re«;-uancy  there  is  a  pure  li\|)ertro|tli\-  (tf  all  the  vauiiial 
tissues.  The  va>:-inal  walls  are  leni;tliene<l,  as  >li(»\\n  l)\'  the  fact  that 
while  tlie  uterus  is  higher  than  normal,  and  the  ruj^te  even  more 
marUed  than  usual,  tlio  nuiet)tis  menil)ranc  is  often  seen  slijjjhtly  jiro- 
lapsed  at  the  vul\:i  duriiit;-  latter  pregnancy.  That  its  calibre  is 
incivased  is  seen  l)y  the  ease  with  Avhich  the  fiu<>;ers,  or  even  the  hand, 
may  be  introduced,  Still,  its  contractility  is  evinced  by  its  ability  to 
expel  the  placenta  when  it  has  been  discharged  into  the  canal  by  the 
uterus. 

Felhnving  pai'turitiou  the  vagina  is  reduced  to  its  normal  dimensions 
by  the  i»roeess  of  involution.  This  process  is  probably  similar  to  that 
which  reduces  the  uterus — a  fatty  degeneration  of  its  hypertrophied 
elements.  When  this  regression  fails  or  is  only  partly  attained  from 
whatsoever  cause,  the  vagina  is  left  loose,  flabby,  and  non-resistant. 
This  is  the  state  of  subinvolution.  The  particular  result  of  this  subin- 
volution will  depend  chiefly  upon  the  cause  and  extent  of  the  condition. 

No  investigation  has  been  made  to  show  the  pathological  histology 
of  the  relaxed  vaginal  walls  in  a  ])ure  subinvolution  ;  and  here,  again, 
we  are  reduced  to  the  uncertainty  of  inference.  From  the  increased 
amount  of  tissue  in  the  organ,  greater  than  normal  and  leas  than  at 
parturition,  we  are  to  infer  that  the  hypertrophied  muscular  fibres  have 
not  all  been  removed.  Like\vise,  the  lack  of  muscular  tone  or  func- 
tional ability  of  the  muscular  fibres  lends  color  to  the  inference  that 
the  sluggish  circulation  causes  such  inefficient  nutrition  that  the  fibres 
are  incapable  of  normal  or  functional  activitv. 

Etiology. — The  causes  of  sul)involution  of  the  vagina  are  mostlv 
the  same  in  kind,  though  differing  in  degree,  as  those  producing  sul)in- 
volution  of  the  uterus. 

To  those  conditions  wliich  bring  about  sul)involution  of  the  uterus 
by  maintaining  ])clvic  congestion  directly  or  indirectly  the  origin  of 
subinvolution  is  chiefly  to  be  referred.  In  addition  to  these  causes, 
already  recited,  may  be  added  subinvolution  of  the  uterus,  which  from 
the  intimate  association  with  the  uterus  and  vagina,  cspeeiallv  bv  the 
middle  muscular  coat,  and  the  intimate  relations  of  the  blood-supplv, 
will  readilv  induce  a  coincident  congestion  in  the  vai2:inal  walls. 


670  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

The  most  importaut  factor  in  etiology  is  injury  to  the  perineum  and 
pelvic  floor.  These  injuries  may  be  divided  into — 1.  Simple  lacera- 
tions of  the  external  perineum  to  the  sphincter  ani  without  injury  to 
the  vagina.  Such  accidents  are  not  so  productive  of  vaginal  relaxation 
as  is  generally  supposed.  In  feeble  women  these  may  lead  to  some 
degree  of  congestion  in  the  vagina,  and  thus  act  as  an  exciting  cause 
of  subinvolution  through  enfeeblement  of  the  general  health. 

2.  Lacerations  of  the  external  perineum  with  the  pelvic  floor,  in- 
cluding the  fascia  and  levator  ani  muscles  in  the  median  line.  In  such 
injuries  the  subinvolution  of  the  vagina  is  induced  by  the  absence  of 
its  chief  supporting  agency,  the  levator  ani  muscles  with  their  strong 
enveloping  fascia.  The  vagina  is  a  loose  shut  sac  extending  downward 
and  forward.  Its  chief  support  is  the  pair  of  levator  ani  muscles,  with 
their  fascia,  meeting  behind  and  below,  by  which  "  drawstring "  the 
vagina  is  slung  up  to  the  anterior  pelvic  wall.  These  nmscles  thus 
directly  support  the  posterior  vaginal  wall,  and  it  in  turn  supports  the 
anterior  wall  and  bladder.  When  this  support  is  removed  by  lacera- 
tion, the  posterior  wall  relaxes  and  pouts  forward  as  a  rectocele,  to  be 
followed  at  times  by  descent  of  the  uterus,  cystocele,  and  prolapsus 
vaginse,  in  order  as  a  result  of  the  subinvolution  produced  primarily 
by  the  injury  to  the  pelvic  floor. 

3.  When  the  laceration  of  the  integumentary  perineum  reaches 
through  the  sphincter  without  injury  to  the  levators  and  their  fascia, 
more  or  less  subinvolution  is  the  result,  although  the  amount  of  the 
disease  and  the  resulting  deformity  are  not  so  rapid  in  their  appearance 
nor  so  marked  in  their  extent. 

4.  When  injuries  No.  2  and  3  are  combined,  subinvolution  of  the 
vagina  occurs  speedily,  and  is  followed  by  the  conditions  noticed  as 
sequelae  of  No.  3.  All  that  was  said  with  reference  to  the  arrest  of 
involution  consequent  upon  the  vascular  hypersemia  which  is  set  up  for 
the  purposes  of  normal  repair  of  the  uterine  cervix  after  laceration  is 
equally  applicable  to  lacerations  of  the  vagina  or  perineum. 

5.  At  times,  and  probably  more  frequently  than  is  generally  sup- 
posed, there  is  separation  of  the  opposite  halves  of  the  levator  ani 
muscle  at  their  median  raph6,  without  any  integumentary  or  mucous 
laceration.  As  a  result,  the  attached  ends  of  the.  muscle  on  each  side 
are  drawn  forward,  leaving  the  posterior  vaginal  wall  unsupported, 
except  by  the  flabby  mucous  membrane  and  the  sagging  tissues  of  the 
perineal  body.  In  such  cases  the  posterior  vaginal  wall  drops  forward 
and  downward,  followed  by  the  rectum,  constituting  a  rectocele.  The 
same  condition  ensues  when  the  levators  suffer  lateral  submucous  rup- 
ture, except  that  when  the  lateral  laceration  occurs  well  forward,  and 
the  median  portions  of  the  two  muscles  remain  posteriorly  to  stiffen  the 
posterior  vaginal  wall,  the  anterior  wall  will  suffer  first,  the  cystocele 


srj:i.\\<>Lrri().\  or  riii:  r.u./.v.i.  G71 

talvinu'  precedence  miiiom^-  the  xa^inal  defuniiilii  s  |)ni<liicetl  1)V  lli<' 
ivsultiiii;-  siil)iiivitluli()ii. 

Since  each  oiie  <»('  the  va^iiial  ilefurniil  ie<  mhmiI  ioiicd  pi-exioii-lv  ils  a 
sec()n«lar\'  resull  nf  iiijurio  to  llie  |icriiiiiiiii  and  pelvic  lloorwill  be 
treated  in  their  appr(»|)riale  places  hy  other  cdnlriluitors  to  this  work, 
thev  will  be  disniisst-d  from  further  consideration  here,  althonirh  in  our 
discussion  of  the  surt»ieal  treatment  ap[)roi)riate  to  subinvolution  these 
deformities  must  necessarily  be  fre(piently  mentioned. 

6.  Those;  cases  where  general  subinvolution  of  tlie  va}i;ina  occurs  :ts 
a  result  of  the  traumatism  done  to  the  parts  during  labor,  without 
either  rupture  or  laceration  of  any  of  the  structures  or  supports  of  the 
vagina. 

Over-distension  of  the  canal  as  a  result  of  a  long  laboi'  in  (eel)le  pa- 
tients may  so  destroy  the  tone  of  the  parts  that  the  venous  eongestion  will 
not  be  overcome  by  the  process  of  involution.  The  fatty  degeneration 
will  occur  only  to  a  limited  extent,  and  by  removing  some  of  the  mus- 
cular fibres,  whose  loss  will  not  be  compensated  by  the  new  fibres  which 
should  take  theii  ])laces  in  the  process  of  re})air,  will  leave  the  canal 
loose  and  flabby  without  contractile  power.  The  relaxed  vagina,  desti- 
tute of  such  muscular  structure  as  by  its  contraction  tends  to  drive  out 
congestion  and  promote  fatty  degeneration,  is  in  a  condition  fiivoring 
further  congestion  and  maintaining  its  own  relaxation.  In  time  the 
condition  simulates  atrophy  of  the  vagina  in  the  feeble  functional  power 
of  its  muscular  elements. 

Not  only  may  such  a  condition  arise  from  over-distension  of  the  canal 
during  parturition,  but  it  may  arise  as  a  maintenance  of  congestion  and 
deficient  involution,  due  to  any  of  the  causes  recited  under  Subinvolu- 
tion of  the  Uterus,  although  it  does  not  always  accompany  the  latter 
condition. 

Excessive  sexual  intercourse,  indejiendent  of  parturition,  will  lead  to 
a  condition  of  vaginal  relaxation  ])ractically  the  same  as  subinvolution 
of  the  vagina  following  parturition.  There  is  not  here,  however,  the 
antecedent  element  of  nuiscular  hvpertrojihy  which  marks  changes  in 
the  vagina  as  uniforndy  as  in  the  uterus  during  ])regnancy.  The 
vagina  does  not  return  to  its  normal  size  and  tone  until  from  eight 
to  twelve  weeks  after  jxirturition,  and  sexual  intercourse  before  this 
time  is  always  at  the  expense  of  proper  involution.  It  should  therefore 
be  positively  forbidden. 

Treatment. — Prophylactic  measures  are  here  important,  cliief  of 
which  is  the  ]n'evention  of  the  traumatism  of  parturition.  AVhat  has 
been  said  in  this  respect  regarding  ])ro])hvlaxis  of  subinvolution  of  the 
uterus  is  equally  true  in  regard  to  the  same  condition  in  the  vagina. 
Indeed,  so  ftir  as  relates  to  lacerations  of  the  vagina  and  ]>elvic  floor,  it 
is  more  important  here  than  in  subinvolution  of  the  uterus,  since  in 


672  SUBINVOLUTION  OF  THE   UTERUS  AND    VAGINA. 

these  injuries  involution  of  the  vagina  is  more  directly  impaired  than 
that  of  the  uterus. 

Every  procedure  indicated  l)y  the  highest  obstetric  skill,  lof>king  to 
the  prevention  of  injuries  to  the  cervix,  vagina,  or  perineum,  is  prophy- 
lactic of  subinvolution  of  the  vagina.  When,  however,  injury,  un- 
avoidable or  otherwise,  does  occur  to  the  perineum,  it  should,  receive 
immediate  surgical  repair. 

The  same  is  true  of  the  vagina.  Immediate  surgical  repair  of  the 
cervix  has  not  yet  received  general  sanction,  although  it  has  been  pro- 
posed in  several  quarters.  In  most  instances  such  a  procedure  is,  for 
obvious  reasons,  impracticable. 

Dr.  Ellwood  Wilson,  in  a  paper  read  before  the  American  Gynecolo- 
gical Society  in  Sept.,  1886,  reports  excellent  results  from  the  applica- 
tion of  nitrate  of  silver  to  the  freshly-torn  surfaces  in  cases  of  lacerated 
cervix,  the  union  being  prompt,  thus  leaving  no  chronic  processes  favor- 
ing subinvolution  of  the  vagina. 

In  all  cases  of  perineal  traumatism  where,  from  any  cause,  the  pri- 
mary operation  for  repair  was  not  successful,  the  secondary  operation 
should  be  done  within  a  few  months,  at  farthest,  belbre  the  necessary 
influences  inducing  subinvolution  have  been  operative  to  a  permanent 
degree.  The  same  course  should  be  followed  in  cases  where  the  pri- 
mary operation  was  neglected.  The  above  remarks  as  to  time  apply 
equally  to  operations  for  laceration  of  the  cervix. 

Not  only  are  the  same  operations,  above  referred  to,  prophylactic  of 
subinvolution  of  the  vagina,  but  the  same  procedures,  done  at  a  later 
period  when  subinvolution  already  exists,  are  frequently  more  promptly 
and  efficiently  curative  than  all  other  measures. 

The  constitutional  treatment,  including  medicines,  baths,  exercise,  air, 
and  diet,  most  appropriate  in  the  treatment  of  subinvolution  of  the  ute- 
rus is  equally  applicable  in  the  same  condition  of  the  vagina.  The 
reader  is  therefore  referred  to  the  foregoing  remarks  upon  that  subject. 

Local  treatment  is  of  signal  value,  and  should  be  employed  in  much 
the  same  manner  as  detailed  in  the  topical  vaginal  treatment  of  sub- 
involution of  the  uterus.  In  using  the  depleting  powers  of  glycerin 
and  the  astringency  of  tannin  and  boric  acid  in  this  disease,  not  only 
should  the  tampons  be  applied  to  the  cervix  in  the  upper  part  of  the 
canal,  but  the  entire  vagina  should  be  loosely  filled  with  pledgets  of 
cotton  well  saturated  with  anhydrous  glycerin,  boro-glyceride,  or  tanno- 
glyceride.  Topical  application  of  tincture  of  iodine  to  the  vaginal 
walls  and  vault  three  or  four  times  per  Aveek  is  often  very  beneficial. 

Electricity. — What  has  been  said  upon  the  use  of  electricity  in  sub- 
involution of  the  uterus  must  be  emphasized  in  the  treatment  of  sub- 
involution of  the  vagina.  Indeed,  it  is  the  most  important  agent  in 
the  treatment  of  cases  not  requiring  surgical  aid,  and  may  sometimes 


suiiiwoi.rriox  of  the  vacisa.  673 

propt'i'lv  siipplciMciit  cnscs  wliiili  \\\\\v  Ikch  MiiLii<"illy  trcMtcd.  'I'Ih- 
i;-alvaiuc  ciii'i'ciit  al(»lH'  sliniiM  lie  ii>t'(l  wlicii  the  disease  is  coiiliiicd  (o 
till'  vagina,  with  oiii-  |)<»lt',  tlic  iiciiativc,  in  the  va<;ina — the  otlier,  the 
j)o.sitiv(.',  in  the  (nrni  of  a  Hat  clcttrodc,  ii|)iin  the  anterior  alxluniiiial 
wall.  It  is  also  well  at  tinie<  to  apply  a  ecntle  enrrent  tlirou^li  the 
posterior  vaginal  wall,  plaeiiii;-  one  pole,  the  negative,  in  the  vajxina, 
and  the  other,  the  po,-iii\c,  in  the  reetiun.  The  current  should  never 
l)e  so  strong;-  as  to  he  j)ainl'nl,  and  the  api)lieation  should  continue  tor 
\cn  to  fifteen  ininules  ahout  three  times  ])er  week.  A  current  of  low 
intenslt\-  and  hiriic  <|Uantity  is  always  the  most  valnahle  in  such  con- 
ilirions.  I'ropei'iv  and  patiently  applied,  no  a^cnt  is  moi'e  useful  than 
lialvanisni  in  stinudatin^- the  ahsoi'hent  process  and  hastening  involution 
in  the  slutiiiish  circulation  of  a  ilahhy  vai2;ina. 

In  emplovino-  ualvanism  to  the  vagina  in  subinvolution  the  following 
general  rules  shoidd  he  observed :  1,  never  use  a  current  so  strong  as 
to  be  painful  ;  2,  in  the  rare  event  that  the  organ  is  tender  and  i)ainful 
use  the  positive  pole,  the  anode,  internally;  3,  otherwise  use  the  nega- 
tive pole,  the  cathode,  internally,  since  the  catalysis  induced  by  it  best 
promotes  the  absorbents ;  4,  avoid  the  cauterization  sometimes  caused 
by  the  negative  electrode  by  having  its  metal  exposure  clothed  Avith 
chamois-skin. 

During  the  employment  of  galvanism,  as  well  as  at  all  other  times 
in  the  treatment  of  this  disease,  the  vagina  should  receive  copious 
irrigations  of  hot  water  daily,  more  especially  just  before  the  patient 
retires. 

The  judicious  use  of  a  pessary  is  often  valuable  treatment,  especially 
when  there  is  some  uterine  descent  increasing  the  congestion  of  the 
upper  part  of  the  vaginal  canal  and  rendering  the  vessels  more  tor- 
tuous. In  such  cases  a  pessary  Avill  sustain  the  uterus,  removing  its 
pressure,  and  slightly  stretch  the  vagina,  straighteuiug  its  canal,  thus 
overcoming  the  congestion,  which  promotes  subinvolution. 

Surr/ical  Treatment. — When  the  disease  is  due  to  vaginal  traumatism 
the  only  recourse  lies  in  surgery.  When  the  deformity  of  the  anterior 
wall  amounts  to  a  condition  of  cystocele,  the  integrity  of  the  part  may  be 
secured  by  Emmet's,  Sims's,  Stoltz's,  Dieffenbach's,  or  Reamy's  operation. 

The  writer  has  practised  for  several  years  an  operation  for  this  con- 
dition which  has  given  him  better  satisfaction  than  any  other,  a  descrip- 
tion of  which  was  published  in  the  Philadelphia  Medical  News  for 
Aug.  8,  1885. 

In  cases  where  there  is  a  rectocele  or  prolapsus  of  the  ])osterior  vagi- 
nal wall,  some  one  of  the  operations  for  narrowing  the  vagina  is  indi- 
cated. Prominent  among  these  procedures  are  the  operations  of  Eiumet 
and  Sims. 

When  the  rectocele  is  associated  with  more  or  less  laceration  of  the 

Vol.  I.— 43 


674  SUBINVOLUTION  OF  THE   UTERUS  AND   VAGINA. 

perineum,  both  conditions  may  be  cured  by  the  same  operation.  In 
this  field  choice  may  be  had  among  the  procedures  of  Simon,  Hegar, 
Martin,  and  Fritsch,  all  of  which  combine  the  dual  objects  of  repairing 
the  perineum  and  lessening  the  calibre  of  the  vagina.  In  the  injury 
to  the  levators  spoken  of  by  Emmet  as  destruction  to  the  "  drawstring  " 
Emmet's  operation  should  be  performed. 

When  prolapsus  of  the  uterus  exists  the  operation  resorted  to  for  its 
cure  also  corrects  the  subinvolution  of  the  vagina.  The  operations  pro- 
posed for  this  condition  are  the  same  in  kind  as  those  devised  for  recto- 
cele  combined  with  perineal  laceration.  The  writer  in  cases  compli- 
cated with  prolapsus  uteri  has  met  with  most  success  in  an  operation 
upon  the  posterior  wall  similar  to  that  already  mentioned  as  performed 
by  him  for  cystocele.^ 

This  operation  is  especially  useful  in  narrowing  the  vagina  at  its 
upper  part  just  below  the  cervix,  at  the  same  time  thickening  the  pos- 
terior wall  in  the  same  situation,  and  finally  restoring  the  perineum. 

In  all  the  foregoing  cases  restoring  the  existing  deformity  proposes 
involution  secondarily  in  two  ways :  First,  by  restoring  more  nearly  to 
the  norm  the  direction  of  the  blood-vessels  and  lymphatics,  and  remov- 
ing undue  pressure  which  has  resulted  from  changed  relation  of  parts. 
Second,  depletion,  removal  of  tissue,  with  union  by  first  intention,  pro- 
mote lymphatic  absorption,  the  removal  of  subinvolution-elements. 

1  See  Phila.  Med.  News,  March,  1887. 


PERIUTERINE  INFLAMMATION. 

IJv    laCIlAUl)    \i.    MAl'UV.    M.  I)., 
Mkmi'His,  Tknn. 


Defixitiox. — This  terra  is  used  to  designate  the  different  forms  of 
inflammation  which  modern  research  has  shown  to  originate  in  the  soft 
tissues  of  the  true  j)elvis  in  woman — the  tissues  lying  outside  the  rec- 
tum and  bladder  and  adjoining  the  uterus,  ovaries,  and  tubes.  Inflam- 
mation is  often  discovered  in  the  tissues  immediately  adjacent  to  the 
uterus  as  a  result  of  some  lesion  of  its  structure,  and  may  not  extend 
beyond  this  locality.  On  the  other  hand,  from  a  greater  lesion  a  more 
destructive  inflammation  may  arise,  and  extend  into  the  broad  liga- 
ments, or  even  beyond  the  limits  of  the  true  pelvis,  so  that  in  conse- 
quence of  such  extension  there  may  result  an  abscess  in  the  iliac  fossa 
or  in  the  cellular  tissue  behind  the  pubes,  or  there  may  be  a  purulent 
collectitMi  in  the  peritoneum,  the  outlines  of  which  will  rise  consider- 
ably above  the  brim  of  the  pelvis.  To  both  these  conditions  it  seems 
quite  proper  to  apply  the  term  "  periuterine." 

Abundant  auto])sical  evidence  can  now  be  adduced  to  prove  that  two 
distinct  forms  of  periuterine  inflammation  may  exist,  each  entirely  inde- 
pendent of,  and  separate  from,  the  other.  To  these  inflammations 
have  been  given  the  names,  according  to  the  tissues  involved,  of  pelvic 
peritonitis  and  pelvic  cellulitis.  To  those  circumscribed  inflammations 
aifeeting  the  cellular  tissue  and  the  peritoneum  immediately  adjoining 
the  uterus  Virchow  gave  the  names  of  parametritis  and  perimetritis. 

History. — It  has  been  claimed  by  some  distinguished  antiquaries 
that  the  ancients  had  a  respectable  knowledge  of  these  affections.  After 
a  careful  review  of  wliat  has  been  written,  I  know  of  nothing  to  prove 
that  the  ancients  had  anv  intelligent  ideas  concernino;  the  real  nature 
of  pelvic  inflammations.  Acute  observers  as  they  were,  it  was  impos- 
sible that  they  could  fail  to  see  that  the  puerperal  woman  was  often 
attacked  with  an  inflammation  in  the  pelvis,  that  not  unfrequently  sup- 
puration occurred,  and  that  the  abscess  discharged  itself  through  the 
vagina,  the  rectum,  or  at  some  point  on  the  cutaneous  surface  in  the 
neighborhood  of  the  uterus.  Yet  when  we  read  the  work  of  him  who 
has  always   been  cited   as  the  foremost  of  the  ancient  gynecologists, 

675 


676  PERIUTERINE  INFLAMMATION. 

Archigenes,  whose  teachings  on  "  Abscess  of  the  Uterus "  have  been 
handed  down  to  us  by  Oribasius  and  by  Aetius,  we  are  forced  to  the 
conclusion  that  he  had  no  knowledge  of  the  tissues  involved,  or  of  the 
cause  or  of  the  proper  treatment  of  these  inflammations. 

It  has  been  reserved  for  the  physicians  of  modern  times  to  truly 
investigate  and  to  elucidate  this  subject,  as  far  as  our  positive  know- 
ledge of  it  goes.  One  of  the  first  contributions  which  should  attract 
our  attention  is  the  work  of  Puzos  of  France,  "  Memoire  sur  les  Depots 
laiteux,"  published  in  1743  as  a  chapter  in  his  Traite  des  Accoiiche- 
ments.  His  view  of  the  nature  of  pelvic  exudations  Avas  that  they 
were  simply  the  result  of  a  metastasis  of  the  milk.  He  locates  these 
"  milky  deposits "  in  the  iliac  fossa,  under  the  skin  and  the  fat,  and 
between  the  muscles  and  the  peritoneum.  "  The  most  important  are 
lodged  in  the  cellular  tissue  of  the  peritoneum,  in  the  broad  ligaments, 
or  in  the  ovaries."  ^ 

JSFo  important  advance  was  then  made  until  ]  843,  M'hen  Professors 
Doherty  of  Galway  and  Churchill  of  Dublin  published  their  view^s  in 
the  Dublin  Journal  of  MecUcal  Science,  the  former  under  the  title  of 
"  Chronic  Inflammation  of  the  Uterine  Appendages  occurring  after 
Parturition ;"  the  latter  under  that  of  "  Inflammation  and  Abscess  of 
the  Uterine  Appendages."  Doherty  pointed  out  some  of  the  most 
important  signs  of  pelvic  inflammation  which  are  to  be  recognized  by 
vasfinal  examination — "the  hardness  which  is  tender  to  the  touch,  and 
as  firm  and  inelastic  as  a  deal  board ;"  also  the  fixation  and  displace- 
ment of  the  uterus,  which  is  bound  down  to  the  affected  side.  Both 
these  men  clearly  dedared  the  occurrence  of  exudations  close  to  the 
uterus  and  within  the  limits  of  the  true  pelvis.  Both  considered  the 
subject  simply  as  pelvic  inflammation.  Neither  undertook  to  discuss  the 
tissues  involved  in  different  forms  of  inflammation. 

The  next  important  contribution  to  which  our  attention  is  directed  is 
tlie  work  of  Marchal  (de  Calvi),  entitled  Des  Abees  jihUgmoneux  intra- 
pelviens,  in  1844.  The  chief  advance  made  by  Marchal  is  in  showing 
that  puerperal  and  other  abscesses  are  often  located  within  the  pelvis. 
Yet  he  does  not  simply  describe  them  as  intrapelvic:  he  goes  farther 
and  specifies  the  different  tissues  involved  in  the  inflammation.  Thus 
from  autopsical  evidence  he  declares  the  existence  of — 1,  abscess  of  the 
subperitoneal  cellular  tissue;  2,  abscess  of  the  subaponeurotic  space;  3, 
ovarian  abscess;  4,  intraperitoneal  abscess.  He  also  recognizes  the  dif- 
ficulty of  distinguishing  during  life  abscess  which  is  the  result  of  a  cellu- 
litis from  those  purulent  deposits  which  arise  from  inflammation  of  the 
pelvic  peritoneum. 

As  time  advances  we  find  arising  differences  of  opinion  in  regard  to 
the  tissue  usually  involved  in  pelvic  inflammations.  Thus  a  very  able 
^  On  Parametritis  and  Perimetritis,  by,  J.  ]\Iatthews  Duncan,  1869,  p.  14. 


K'nofjx.y.  077 

obsciAcr,  Ail^ii-lf  Ndii.Ml,  ill  l.S.">()  insisted  lli.it  llic  iii(l;iiiiiii;itin y  >\\ill- 
ino>4  ill  tlif  |)('1\  is  were  all  located  in  iIh'  cclliilai'  tissue,  and  that  tiie 
|K'rit()Meiuii  w.is  iKil  iiiNolved.  To  tlie>e  swclliiiiis  lie  ai»[)licd  the  term 
"periuterine  |»hlei;iiii)n."  M.  IJernutz,  on  the  nther  hand,  in  a  reniark- 
al)le  series  of  investioutions,  to  be  noticed  at  leiiiitii  in  another  j)Iuee, 
demonsti-ati'd  that  the  pelvic  iuHaniniations  coinin»i,-  inulei-  his  observa- 
tion occniTcd  at  the  expense  of  the  pelvic  peritoneum,  and  that  the 
(H'lJnlai-  tissue  was  usually  not  to  auy  degree  invaded.  He  acknow- 
ledi;-es  the  oxisteneo  of  phleijinons  of  the  broad  ligaments,  but  adds 
that  "  they  ought  to  be  studied  with  plilegmons  of  the  iliac  fossa,  of 
wliicli   they  are  a  very   interesting  variety." 

8ubse([uent  writei-s  have  leaned  to  one  or  the  other  side  of  this  con- 
troversy, being  influenced  to  some  extent,  perhaps,  by  the  weight  of 
authority  or  else  drawing  their  conclusions  from  the  character  of 
the  clinical  material  furnished  by  the  limited  field  of  their  own 
observations. 

In  1868,  in  .1  Practical  Treatise  on  the  Diseases  of  Women,  Dr.  T. 
Gail  lard  Thomas  presented  this  subject  in  what  I  believe  to  be  its  true 
light.  From  clinical  and  post-mortem  observation  Dr.  Thomas  accepted 
the  teachings  of  Bernutz.  He  moreover  acknowledged  the  independent 
existence  of  two  distinct  forms  of  pelvic  inflammation,  which  he  described 
as  periuterine  cellulitis  and  pelvic  peritonitis.  He  declared  that  while 
they  frequently  coexist,  they  are  entirely  distinct  from  each  other;  that 
they  may  usually  be  diiferentiated ;  and  that  an  effort  at  thorough  diag- 
nosis should  ah\ays  be  made.  He  furthermore  formulated  rules  for  a 
differential  diagnosis. 

During  the  same  year  this  work  was  followed  by  the  well- 
known  treatise  of  Dr.  J.  Matthews  Duncan  On  Perimetritis  and 
Parametriflx.  This  author  likewise  recognized  tAvo  distinct  forms  of 
periuterine  inflammation,  and  also  the  importance  of  distinguishing 
them ;  and  while  he  rejected  the  attempt  at  diagnosis  made  by  Dr. 
Thomas,  he  acknowledged  our  indebtedness  to  that  writer  "  for  even 
attempting  the  difficult  task."  Since  that  time  accumulated  observa- 
tion ha.s  served  to  make  perfectly  clear  the  truth  of  the  jn'opositions 
stated  by  these  writers. 

Etiology. — As  early  as  1853,  Dr.  J.  Matthews  Duncan  declared,  in 
substance,  that  periuterine  inflammations  were  not  to  be  regarded  as 
separate  primaiy  aifections,  but  that  they  were  secondary  in  their  nature 
and  dependent  upon  inflanunation  of  the  uterus  or  its  a]ipendages. 
Prior  to  the  date  above  mentioned  medical  opinion  upon  this  subject 
had  scarcely  taken  definite  form,  although  a  number  of  writers — among 
whoni  may  be  mentioned  Velj^eau,  ^Nlarchal,  ^NTcClintock,  "West,  and 
Aran — had  in  a  casual  way  expressed  the  belief  that  pelvic  abscesses 
were  often  traceable  to  diseases  of  the  uterus.     At  the  present  time  the 


678  PERIUTERINE  INFLAMMATION. 

general  correctness  of  this  doctriue  is  universally  admitted  by  gyneco- 
logical ^vriters. 

According  to  Winckel/  it  has  been  clearly  shown,  from  the  researches 
of  Virchow,  Waldeyer,  and  others  into  the  pathology  of  the  puerperal 
inflammations,  that  in  pelvic  cellulitis  the  lacerations  and  ulcers  of  the 
cervix  resulting  from  parturition  produce  at  first  tumefaction  and  albu- 
minous infiltration  of  the  intermuscular  connective  tissue  of  the  uterus  : 
then  follow  enlargement  and  proliferation  of  the  connective-tissue  cor- 
puscles. The  same  process  extends  to  the  connective  tissue  around  the 
uterus  and  the  upper  part  of  the  vagina  and  at  the  base  of  the  broad 
ligaments  and  into  the  tissue  between  the  folds  of  the  broad  ligaments. 
At  a  later  stage  purulent  deposits  are  formed  in  these  and  in  other 
]oarts  of  the  pelvis. 

The  same  researches  teach  us  that  pelvic  peritonitis  may  result  from 
direct  injury  to  the  peritoneum  by  laceration  through  the  cervix  uteri 
or  from  contusion  of  this  membrane  in  difficult  instrumental  labors. 
Often  it  originates  in  an  endometritis  which  extends  through  the  inter- 
muscular connective  tissue  of  the  uterus  to  the  parametric  tissue,  and 
from  this  to  the  peritoneum.  ISTow  and  then  the  endometritis  spreads 
through  the  tubes  and  involves  the  peritoneum  by  continuity  of  tissue. 

The  non-puerperal  inflammations  recognize  a  similar  etiology.  Trau- 
matism in  the  cervix  and  body  of  the  uterus  from  the  various  surgical 
procedures  of  gynecology,  disease  of  the  ovaries  and  Fallopian  tubes, 
and  extension  of  inflammation  from  the  endometrium  through  the 
tubes,  will,  in  the  vast  majority  of  cases,  clearly  account  for  them. 

A  study  of  the  views  of  the  foremost  obstetrical  writers  of  the  pres- 
ent age  will  show  that  they,  with  few  exceptions,  believe  that  the 
puerperal  inflammations  are  the  res?ult  of  the  introduction  of  septic 
material  into  the  blood,  and  that  the  avenue  by  which  the  poison  gains 
admission  is  furnished  by  the  lesions  of  the  genital  canal.  This  is  the 
view  now  generally  accepted  by  modern  pathologists  in  explanation  of 
the  phenomena  of  surgical  inflammation  wherever  it  may  arise ;  and  to 
set  forth  this  important  subject  in  clear  language  I  quote  the  words 
of  the  late  Dr.  William  H.  Van  Bnren,  a  writer  who  was  renowned 
alike  for  his  deep  learning  and  his  conservatism.  According  to  this 
author,^  "The  terms  infective  and  non-infective,  introduced  by  Simon  and 
Sanderson,  have  been  so  generally  adopted  in  treating  of  surgical  inflam- 
mations and  fevers  as  to  require  special  definition. 

" '  An  inflammation,'  says  Sanderson,  '  which  is  more  or  less  exactly 
limited  in  duration  and  extent  by  the  limits  of  the  injuiy  which  has 
caused  it  may,  with  scientific  precision,  be  designated  a  simple  or 
normal  inflammation ;'  that  is,  non-infective. 

1  The  Pathology  and  Treatment  of  Childbed,  translated  by  Jas.  E.  Chadwick.  1876. 
^  Internal.  Encyclopaedia  of  Surgery,  vol.  i.,  "  Inflammation,"  p.  105. 


ETIOIJXIY.  (J7i) 

"On  (lie  fiiiiti'ai'v,  'all  iiillanmiatinii  wliidi  .-|>r('a<ls  :iii<l  ('iidurcs 
Ix'voiitl  the  direct  and  pi'iiiiary  ((piTatinn  oi"  its  cause,  wliicli  induces 
similar  inllaninialions  in  other  j)afts,  and  disorders  the  vital  luiictifjus 
of  llie  whole  l>od\ ,  has  in  it  soniethinj;-  beyond  the  ellects  ol"  the  injury, 
and  niav  he  projx'i'ly  ti'i'nied  ////rc//Vr.' 

"In  the  latest  lOn^lish  systenialie  woi-k  on  |)alholoMy  ( hy  T.  ihnry 
(Ireen,  etc.,  London,  1  SS  I  )  this  is  s|»ok<'n  ol"  as  one  of  the  nio.-t  iniporl- 
anl  divisions  of  inflaniniation  ;  and  it  is  stateil  that  '  in  all  infective 
iiifiatnniations  the  iorniation  of  the  infective  ,sul)stunee  appears  to  he 
due  to  the  j)resenee  of  minute  or}»anisms,  these  organisms  in  the  or- 
dinar\-  iion-speeilic  inflammations  heing  the  common  sej)tic  bacteria.'  " 

Whilst  eonsideiMng  the  etioloiiy  of  pelvic  iiiHammations  1  would  call 
attention  to  an  instructive  ai-ticle  by  Dr.  Paul  Munde,'  in  \vhi<h  he  has 
placed  before  the  English  reader  the  residt.s  of  the  investigations  of 
Chanij)ionniere  of  Paris  and  Leopold  of  Leipzig  into  the  minute 
anatomy  of  the  uterine  lyniphatics.  These  authors  have  shown  that 
the  Ivmphatie  system  of  the  female  pelvis  consists  of  a  very  luxuriant 
and  intricate  system  of  vessels  opening  by  multitudes  of  luinute  orifices 
upon  the  mucous  surface  of  the  uterus,  and  continuous  with  the  lymph- 
S])aces  of  the  pelvic  peritoneum.  As  these  lymphatic  canals  coalesce  to 
form  larger  vessels,  they  are  seen  in  places  to  form  ganglion-like  expan- 
sions and  to  be  interrupted  here  and  there  by  glands,  the  most  import- 
ant and  constant  of  which  are  situated  in  the  cellular  tissue  on  the  sides 
of  the  cervix.  Leaving  the  walls  of  the  uterus,  they  travel  outwardly 
between  the  layere  of  the  broad  ligament  to  empty  their  contents  into 
the  general  lymphatic  system  of  the  body.  A  more  perfect  mechanism 
for  taking  up  and  conveying  poisonous  material  from  the  lining  mem- 
brane of  the  genital  passages  to  the  periuterine  tissues  could  scarcely  be 
designed. 

^^'hile  the  active  part  played  by  the  lymphatics  in  the  puerperal 
inflammations  has  been  fully  recognized  by  obstetric  writers  of  every 
nation,  as  Dr.  ^Munde  says,  "their  influence  in  the  transmission  of  sep- 
tic matter  and  production  of  inflammation  of  the  uterine  adnexa  in 
the  non-prer/nant  state  has  by  no  means  received  the  recognition  it 
deserves."  In  another  connection  he  adds  :  "And  thus,  while  all  authors 
on  diseases  of  women  speak  of  metritis  and  endometritis,  of  cellulitis  and 
peritonitis,  and  of  ovaritis,  scarcely  one  mentions  the  subject  of  peri- 
uterine lymphangitis  or  lymphadenitis.  What  is  considered  and 
described  as  one  of  the  chief  factors  of  jiuerperal  disease  is  wholly 
overlooked  in  the  non-puerperal  condition." 

Notwithstanding  all  that  has  been  said,  it  must  be  admitted  that 
there  is  a  class  of  cases,  few  in  number,  the  etiology  of  which,  in  the 

'  Amer.  Jonmal  of  Obstetrics,  Oct.,  1883,  "Non-puerperal  Pelvic  Lymphadenitis  and 
Lymphangitis." 


680  PERIUTERINE  INFLAMMATION. 

present  state  of  knowledge,  is  obscure.  Thus  in  young  girls  and  old 
women  pelvic  inflammations  now  and  then  are  met  with,  going  on  to 
suppuration,  in  the  absence  of  any  discoverable  uterine  disease. 

In  this  connection  allusion  should  be  made  to  the  views  of  Dr. 
Thomas  Addis  Emmet.  This  distinguished  gynecologist  says :  ^  "  My 
convictions  are  that  Avhile  the  primary  cause  of  uterine  disease  lies, 
through  the  influence  of  the  sympathetic  system,  in  impaired  nutrition, 
we  must  look  to  pathological  changes  in  the  connective  tissue  as  the 
immediate  cause  of  the  results  we  now  regard  as  the  original  disease 
in  the  uterus  and  ovaries.  These  views  have  no  reference  to  the 
puerperal  state,  for  there  I  recognize  the  direct  susceptibility  of  the 
uterus  to  disease  and  mechanical  injury.  Pathological  changes  are 
then  brought  about  in  the  connective  tissue  of  the  pelvis  as  secondary 
to  the  uterine  condition,  and  may  remain  long  after  the  original  lesions 
have  disappeared.  But  these  pathological  changes  may  afterward  so  far 
affect  the  circulation,  either  mechanically  or  through  the  nervous  system, 
as  to  become  the  cause  of  new  and  other  forms  of  uterine  disease."  Dr. 
Emmet  classifies  the  causes  of  pelvic  inflammations  as  puerperal  and 
accidental,  and  says :  ^  "  I  am  deeply  impressed  with  the  belief  that 
future  observation  will  establish  the  fact  that  the  point  of  origin  of 

inflammation  in  the  pelvic  cellular  tissue  is  in  the  veins That 

phlebitis  in  the  pelvic  cellular  tissue  does  arise  in  the  puerperal  state 
was  taught  by  Trousseau,  and  I  verified  it  in  the  earlier  part  of 
my  professional  life,  when  my  opportunities  were  better  for  studying 
pathological  changes ;  but  it  must  be  left  to  future  observation  to 
determine  why  and  how  it  occurs  in  the  non-puerperal  condition,  for 
I  have  had  no  opportunity  of  establishing  this  point." 

To  the  two  forms  of  pelvic  inflammation  given  above  Prof.  Courty 
of  Montpellier  has  added  a  third.  To  this  he  gives  the  name  of  peri- 
uterine adenitis  and  angeioleucitis.  From  his  description  we  learn  ^  that 
this  affection  "  is  often  acute  and  the  prognosis  very  serious  when  it  is 
puerperal ;  more  frequently  it  is  chronic,  and  is  then  less  important  in 
itself  than  from  the  ulceration  of  the  uterine  mucous  membrane,  of 
which  it  is  the  certain  sign." 

The  autopsies  of  Championniere,  Leopold,  and  others  have  shown 
that  in  the  puerperal  inflammations  the  lymphatics  are  commonly  filled 
with  pus. 

According  to  Courty,  acute  inflammation  of  the  periuterine  lymphatic 
ganglia  and  vessels  is  observed  as  a  result  of  traumatic  causes,  of  endo- 
metrial inflammation,  or  of  the  participation  of  these  structures  in  an 
acute  periuterine  inflammation.     Most  frequently,  however,  angeioleu- 

^  The  Principles  and  Practice  of  Gynecology,  3cl  ed.  ^  Op.  cit,  p.  245. 

^  A  Practical  Treatise  on  the  Diseases  of  the  Uterus,  Ovaries,  and  Fcdlopian  Tube,?,  trans- 
lated from  the  3d  ed.,  p.  537. 


FRKQVEyaY.  <).Sl 

citis  aiitl  iitlciiilis  dcciir  in  (lie  clii'miii'  Iniiii.  I  ln'  <liH;i>c  i-  linn  i-cc(»h^- 
nizetl  li\'  llif  occiirrciKH!  ol"  small  rtniiulcd  tiinioi'.s,  smodlli  at  (•(■itaiii 
points,  irrciiular  at  others,  situated  l)eliin<l  and  to  the  sides  ol'  the  cer- 
vix, and  h>oseIy  connected  with  the  nteiuis  and  va<i;inal  cids-de-siic. 
'riie^e  liunors  are  smaller  than  the  normal  ovary,  are  less  movalWe,  and 
usiiailv  less  ])ainf"ul  on  [)ressni'e  than  this  or^an,  hut  in  some  eases  are 
very  tender  to  the  touch. 

The  uterus  is  ircnerally  movable  and  often  retroverted.  "  Apart 
from  the  sym|)toms,  either  direct  or  sym[)ath{!tic,  of  the  uterine  malady 
and  of  the  ulcer  which  has  caused  it,  jieriuterino  adenitis  has  sp(!cial 
symptoms  characterizin<;-  it:  lumbar  or  lumbo-sacral  pain,  sometimes 
cxtendini>;  to  the  anus;  continuance  of  the  [)ains  previously  experienced 
by  the  patient,  which  are  increased  by  marital  intercourse,  evciu  when 
most  of  the  apj)arent  uterine  symptoms  have  disappeared;  pain  elicited 
by  diii'ital  touch,  especially  Avhen  pressure  is  exercised  by  the  finger 
behind  the  uterus  and  laterally,  and  when  an  attempt  is  made  to 
depress  the  retro- or  dextro-uterine  cul-de-sac."^  This  descrijjtion  by 
Prof.  Courty  is  based  not  only  on  clinical  observation,  but  also  upon 
autopsical  evidence  drawn  from  a  woman  at  the  age  of  forty  who  died 
of  [)neumonia  after  suffering  a  long  time  from  leucorrhoea  and  ulcerous 
endometritis. 

Dr.  J.  S.  Carreau "  of  New  York  and  Dr.  Paul  Munde  ■^  have  each 
reported  a  number  of  cases  of  this  form  of  periuterine  inflammation. 

Fkequexcy. — It  is  impossible  to  give  statistics  which  will  fix  with 
accuracy  the  frequency  of  occurrence  of  these  inflammations.  It  is 
sufficient  to  state  that  they  are  the  most  common  of  all  the  disorders 
of  M'omen,  and,  in  the  language  of  Courty,^  "  it  is  certain  that  out  of 
100  women  there  will  be  55  with  peritoneal  adhesions  and  showing 
traces  more  or  less  intense  of  pelvic  peritonitis.  Of  this  number  there 
are  far  more  married  women  than  virgins,  and  more  nuiltipar;e  than 
primipara?." 

Inasnuich  as  a  thorough  acquaintance  with  the  peritoneum  and  cell- 
ular tissue  of  the  pelvis  is  essential  to  a  correct  interpretation  of  pelvic 
exudations,  an  account  of  the  most  important  anatomical  features  of 
these  structures  is  here  presented. 

*  Courty,  op.  ciL,  p.  539. 

*  "Adenitis  and  Angeioleucitis  of  the  Pelvic  Cellular  Tissue,"  MixUml  Record,  July 
2,  1881. 

'  "  Non-puerperal  Pelvic  Lvnaphadenitis  and  Lvmphan<^itis,"  Am.  Journ.  Obs(.,  Oct., 
1883. 

*  Op.  cit.,  p.  540. 


682  PERIUTERINE  INFLAMMATION. 

The  Pelvic  Peritoneum. 

The  peritoneum,  after  lining  the  walls  of  the  abdomen,  descends  into 
the  true  pelvis  and  throws  itself  as  a  covering  over  all  of  its  viscera. 
The  floor  of  the  pelvis,  thus  covered,  is  not  a  smooth  surface,  but  pre- 
sents many  irregularities.  Looking  down  into  its  cavity,  we  observe 
that  the  pelvis  is  divided  quite  evenly  into  anterior  and  posterior  spaces 
by  a  prominent  transverse  fold  which  extends  from  one  lateral  wall 
to  the  other.  Within  the  two  layers  which  constitute  this  fold  lies 
the  uterus,  and  on  each  side  of  it  are  the  ovary  and  Fallopian 
tube. 

That  portion  of  the  fold  which  extends  from  the  uterus  to  the  pelvic 
wall  and  embraces  the  ovary  and  tube  is  the  broad  ligament.  Accord- 
ing to  the  statement  of  Hodge,  which  has  recently  been  confirmed  by 
the  investigations  of  Professor  Polk,^  the  broad  ligament  in  the  nullip- 
arous  woman  is  attached  at  its  outer  margin  along  a  vertical  line  run- 
ning between  the  sciatic  notch  behind  and  the  obturator  foramen  in 
front.  The  base  of  the  broad  ligament  can  be  touched  by  the  examin- 
ing finger  in  the  lateral  fornix  of  the  vagina,  except  during  gestation, 
and  its  outline  can  be  distinctly  felt  whenever  the  ligament  has  been 
indurated  by  inflammation. 

In  front  of  the  transverse  fold  just  mentioned  is  a  convex  surface 
corresponding  to  the  bladder,  bounded  on  the  sides  by  two  curving 
folcls — the  round  ligaments — which  emanate  from  the  anterior  and 
superior  margins  of  the  uterus,  sweep  around  the  sides  of  the  bladder, 
and  seek  attachment  near  the  external  abdominal  ring.  . 

The  reflection  of  the  peritoneum  upon  the  anterior  surface  of  the 
uterus  after  covering  the  bladder  is  called  the  vesico-uterine  pouch. 
Of  this  Dr.  Hart  ^  says :  "  It  does  not  contain  intestine  when  the 
uterus  is  normal  in  position,  and  has  therefore  been  unfortunately 
named  '  pouch.' " 

That  portion  of  the  pelvic  floor  which  lies  behind  the  uterus  and 
broad  ligaments  presents  three  well-marked  depressions  or  pouches. 
These  pouches  are  separated  by  two  folds  of  peritoneum  called  the 
folds  of  Douglas  and  also  the  utero-sacral  ligaments.  These  ligaments 
spring  from  the  lower  lateral  part  of  the  body  of  the  uterus  and  pass 
outward  and  backward  to  the  second  sacral  vertebra. 

The  central  depression  between  the  utero-sacral  ligaments,  and  imme- 
diately behind  the  uterus,  is  the  pouch  of  Douglas.  Behind  the  pouch 
of  Douglas  is  the  rectum.  The  two  lateral  depressions  have  been  called 
by  Polk  the  "  retro-ovarian  shelves."  ^ 

^  "  The  Topographical  Eelations  of  the  Female  Pelvic  Organs."  by  Ambrose  L. 
Ranney,  Amer.  Journ.  of  Obstetrics,  April,  1883. 

2  Atlas  of  Female  Pelvic  Anatomy,  p.  43.  ^  Eanney,  loc.  cit.,  p.  367. 


Till':  rr.iAic  I'lJirroNEUj^f. 


(;.s;j 


I'Ik'  narts  al><)V('  (Icsci'ilicd  an-  well  >li(i\\  ii  in  llic  a<'<-<>iii])aiiyiii;^  dia- 
graiiiinatic  viow  of  tlic  pcKis,  rioin  llod^c  (Fi^.  200j. 

While  stuclviiii;'  the  ixTitoiiciiin  \\v.  oWsci'vc  that  in  its  course  down- 
ward, alter  t'overinu-  (lie  posterior  wall  of  llie  uterus,  when  on  a  lev(-l 
with  the  OS  iuternum,  ii  tiu-ns  backward  and  a  little  upward  in  order 
to  cover  the  posterior  fornix  vai;in:e.  it  then  descends  alon«;-  the  |to— 
terior  wall  of  the  va<iina  a  variable  distance  before  it  is  relleeted  upon 

Fio.  2U0. 


A  Diagraiiimatic  Superior  Viow  oi'  the  Fciuak'  Pelvis,  showing  the  reflections  of  the  pelvic 

peritnueuni  (Hodgel. 


the  rectum.  This  variability  in  the  point  of  reflection  is  one  of  the 
most  important  peculiarities  of  Douglas's  pouch. 

Generally,  the  reflection  occurs  on  a  level  with  the  os  externum ; 
occasionally,  higher  up,  on  a  level  with  the  posterior  fornix  ;  rarely 
and  abnormally,  as  low  down  as  one  inch  from  the  vaginal  orifice. 
Pirogoff  has  jirescnted  a  frozen  section  in  which  the  peritoneum  riuis 
down  to  the  very  apex  of  the  peritoneal  body. 

The  boundaries  of  Douglas's  pouch  may  be  stated  thus:  in  front,  the 
supravaginal  portion  of  the  cervix  and  the  upper  portion  of  the  vagina; 
behind,  the  rectum ;  on  the  sides,  the  utero-saeral  ligaments.     Accord- 


684  PERIUTERINE  INFLAMMATION. 

ing  to  Hart,  its  depth  is  somewhat  greater  on  the  left  of  the  uterus 
than  on  the  right. 

It  thus  appears  that  all  the  depressions  in  the  pelvic  floor  are  poste- 
rior to  the  uterus  aud  the  broad  ligaments.  It  is  true,  there  is  in  the 
anterior  half  of  the  pelvis  what  is  called  the  utero-vesical  pouch,  but 
it  is  shallow  or  does  not  exist  at  all  when  the  bladder  is  distended,  and 
is  of  no  clinical  importance. 

While  the  posterior  pouches,  especially  that  of  Douglas,  may  become 
the  seat  of  encapsulated  serous  or  purulent  effusions  in  pelvic  peritonitis, 
anything  like  a  mass  of  peritoneal  exudation  in  the  anterior  half  of  the 
pelvis  is  exceedingly  rare. 

When  a  vertical  mesial  section  of  the  pelvis  is  made  and  the  peri- 
toneum shown  in  profile,  it  will  be  seen  that  the  plane  in  which  it  lies 
is  considerably  below  the  plane  of  the  brim  of  the  pelvis. 

That  portion  of  the  pelvic  cavity  which  lies  above  the  peritoneum 
has  been  denominated  the  peritoneal  space,  while  that  portion  which  lies 
below  it  is  called  the  subperitoneal  space.  The  subperitoneal  space  is 
one  in  which  we  are  deeply  interested,  since  it  contains  not  only  all  the 
pelvic  viscera,  but  the  pelvic  connective  tissue  which  binds  them  together, 
and  with  them  the  blood-vessels,  lymj)hatics,  and  nerves. 

The  Pelvic  Connective  Tissue. 

The  pathological  anatomy  of  the  subperitoneal  pelvic  space  is  per- 
haps of  more  importance  than  any  other  one  subject  connected  with 
the  diseases  of  women.  In  this  space,  underlying  the  peritoneum  and 
investing  the  viscera  and  blood-vessels  throughout  the  pelvis,  is  found 
the  connective  tissue. 

The  uterus,  vagina,  and  their  arterial  and  venous  plexuses  are  all 
enclosed  in  connective  tissue,  and,  as  Savage  ^  remarks,  "  This  uterine 
cellular  system  is  continuous  at  its  periphery  with  every  portion  of  the 
subperitoneal  cellular  tissue  at  the  lower  part  of  the  abdomen." 

Although  loose  connective  tissue  is  found  everywhere  throughout  the 
pelvis,  lying  between  the  different  structures  and  binding  them  together, 
it  is  in  some  places  very  scant  and  in  others  quite  abundant.  With 
special  reference  to  the  clinical  appreciation  of  inflammatory  deposits 
in  the  pelvis,  T  may  mention  those  localities  in  which  the  connective 
tissue  is  found  in  considerable  quantity  : 

1.  Behind  the  symphysis  pubis  and  in  the  angle  between  the  urethra 
and  the  anterior  wall  of  the  bladder,  continuous  with  the  cellular  tissue 
of  the  abdominal  wall — the  retro-pubic  fat  deposit  of  Hart. 

2.  Between  the  posterior  wall  of  the  bladder  and  the  anterior  wall 
of  the  cervix,  on  a  level  with  the  os  internum,  and  between  the  posterior 

^  The  Surgery  of  the  Female  Pelvic  Organs,  2d  ed.,  18S0. 


Tin:  PKLVIC  CONNECTIVE  TISSUE. 


(iH.i 


surthcc  <t("  the  su|>i';iv:it:iii:il  |MHtiiiii  nj"  ilic  cervix  niul  tin-  fold  ol"  jm  ri- 
toiK'Uiii  which  turns  duwii  to  cdvcr  the  jtostcrior  wall  of"  the  va<j;iiia  in 
its  iij)|KT  j)art.  Indeed,  this  jxirtion  oC  the  <'<'rvix,  together  with  the 
upper  portion  of  the  va<;ina,  i>  coniph-tely  surrounded  by  a  fold  of" 
loose,  fatless  ('oiineetivc  tissue  al)undaiitly  supplietl  witli  blood-vessels 
and   lyniphatiis. 

3.  Alonir  the  line  ul"  junctiiHi  of  the  broad  ligaments  with  the  uterus, 
bi'twcon  their  folds,  there  is  a  large  amount  of  coimeetive  tissue  with 
numerous  large  blood-vessels.     This  tissue  lessens  in  amount  as   the 

Vu..  201. 


Lateral  Sagittal  Pection  of  Pelvis  at  junction  of  broad  ligament  and  nteru:<  (Hart) :  D,  vagina : 
A,  bladder;  C,  symphysis;  F,  broad  ligament ;  G,  ovary;  H,  Fallopian  tube. 


broad  ligaments  leave  the  uterus.  This  is  well  shown  in  Fig.  201, 
which  is  a  lateral  sagittal  section  of  the  ])elvis  at  the  junction  of  the 
broad  ligament  and  uterus,  taken  from  Plart.^ 

Between  the  anterior  rectal  wall  and  the  posterior  wall  of  the  vagina, 

*  Op.  cit.,  plate  xxii.  fig.  4. 


686  PERIUTERINE  INFLAMMATION. 

from  the  lowest  point  of  Douglas's  pouch  to  the  apex  of  the  perineal 
body,  there  is  loose  connective  tissue. 

The  connective  tissue  lying  between  the  peritoneum  and  the  body  of 
the  uterus  on  its  anterior  and  posterior  surfaces  is  too  small  in  amount 
to  be  of  clinical  importance. 

In  all  the  localities  above  mentioned  inflammatory  exudations  occur, 
and  can  be  readily  appreciated  by  the  touch ;  but  that  portion  of  the 
connective  tissue  which  overshadows  all  others  in  pathological  import- 
ance is  the  loose  fatless  layer,  three-fourths  of  an  inch  in  thickness, 
which  surrounds  the  supravaginal  cervix  and  the  upper  portion  of  the 
vagina.  According  to  Spiegelberg,^  "  It  was  especially  for  the  puerperal 
inflammations  of  these  cellular  sheaths  that  Virchow  introduced  the 
word  '  parametritis.' " 

The  very  great  importance  of  this  tissue  in  the  etiology  of  periuterine 
inflammations  arises  from  its  intimate  connection  with  the  tissue  of  the 
cervix,  it  being  continuous  with  the  intermuscular  connective  tissue  of 
the  uterus ;  from  the  facility  with  w^hich  it  becomes  involved  in  the 
puerperal  lacerations  of  the  cervix  or  the  injuries  which  the  neck  may 
sustain  from  gynecological  operations;  and  lastly,  from  the  readiness 
with  which  its  numerous  lymphatics  and  blood-vessels  take  up  and 
carry  into  the  system  septic  poisons. 

These  peculiarities  of  the  circumuterine  cellular  tissue  should  remind 
the  gynecologist  of  the  risks  which  attend  and  may  follow  the  most 
trifling  injury  of  the  cervix,  and  should  make  him  ever  cautious  to 
avoid  the  possibility  of  septic  infection  of  these  structures. 

The  Lymphatics  of  the  Uterus. 

A  knowledge  of  the  lymphatic  vessels  and  ganglia  in  the  uterus  and 
its  appendages  must  necessarily  throw  much  light  upon  the  subject  of 
periuterine  inflammation,  inasmuch  as  these  structures  are  closely  related 
to  the  connective  tissue  and  constitute  the  principal  avenues  through 
which  poisons  find  entrance  to  the  system. 

According  to  Dr.  Hart,^  "  The  lymphatics  take  their  origin  in  con- 
nective tissue.  Thus,  the  lymphatics  of  the  uterine  mucous  membrane 
begin  in  the  spaces  between  the  bundles  of  fibrous  connective  tissue, 
these  said  bundles  being  covered  in  part  by  endothelial  cells ;  that  is, 
the  lymphatics  begin  in  spaces  bounded  by  the  endothelial  covering 
of  connective-tissue  bundles. 

"  From  these  the  lymphatic  capillaries  spring  and  merge  into  the 
larger  vessels,  ultimately  opening  into  the  thoracic  duct,  which  of 
course  pours  into  the  venous  system." 

^  German  Clinical  Lectures,  2d  Series,  New  Sydenham  Soc,  1877,  p.  172. 
^  Op.  cit,  p.  29. 


I'h'iAic  ri:i!ir<)srns.  (;,h7 

''  Ij('(i[)oI(1  ('(Hisidci's  the  iilcriiic  iuiicdiis  iiHMuhraiK!  as  a  Iviiiiilialic 
ij;laii(l,  or  lyiupliaticr  surlacc  iiilorsoctcd  witli  utcriiu;  jrlaiid.-  and  Mood- 
vi'sscls,  tlio  IyiM[)halics  Ikmiih"  not  mere  vosst'ls,  hut  .s[)a<'cs  licfwccii  (Ik; 
connectivo-tissiie  hundlcs." 

Lymj)liatie  vossels  orininaliiiii;  in  diU'ci-cnt  [xirtions  of  tlio  jr(;nital  canal 
cany  their  contents  to  diilcrcntly  .situated  inlands.  Thus  the  Ivniphatics 
of  tlie  hibia,  of  the  vai^inal  orifice,  and  lower  [)ortion  of  the  va<i;ina  o[)en 
into  the  iuf^uinal  <>huids.  According  to  Le  Bee,  the  lymphatics  of  the 
upper  portion  of  the  vagina  unite  with  those  of  the  cervix  uteri  at  the 
level  of  the  isthmus  uteri.  They  then  travel  below  the  base  of  the 
broad   ligament  and  empty  into  the  obturator  ganglion. 

From  the  investigations  of  Leopold  it  appears  that  the  lymphatics 
of  the  uterus  originate  in  the  lymph-spaces  of  the  uterine  mucous  nuini- 
brane.  These  lymph-spaces  extend  a  little  way  into  the  funnel-shaped 
hollows  between  two  muscular  bundles,  and  then  into  the  intermuscular 
spaces.  When  the  external  muscular  layer  of  the  uterus  is  reached,  the 
lymph- vessels,  after  surrounding  all  the  bundles,  run  into  large  valved 
canals  at  the  sides  of  the  uterus,  and  then  pass  into  tubes  in  the  broad 
ligament.  These  vessels,  along  with  those  from  the  ovary  and  Fallo- 
pian tube,  empty  into  the  lumbar  glands.  Lesions  of  the  body  of  the 
uterus  and  lesions  of  the  cervix  may  therefore  be  expected  to  give  rise 
to  differently  situated  periuterine  inflammations. 

All  that  is  known  upon  this  subject  is  admirably  presented  and  beau- 
tifullv  illustrated  in  Hart's  magnificent  work. 


Pelvic  Peritonitis. 

Synonym. — Perimetritis  (Duncan,  Fritz). 

The  term  pelvic  peritonitis  is  here  applied  to  an  inflammation,  acute 
or  chronic,  of  the  pelvic  peritoneum.  It  often  involves  also  the  peri- 
toneal covering  of  adjacent  portions  of  the  intestines. 

The  earliest  scientific  knowledge  which  we  possess  in  regard  to  this 
affection  is  derived  from  the  labors  of  Bernutz.  His  in vesti stations 
were  first  published  in  the  Archives  generales  de  JTedecine  for  1857,  and 
subsequently,  in  niore  complete  form,  in  the  CUnique  medicale  des 
Femmcs  in  1862  by  Bernutz  and  Goupil.  This  great  work  of  Bernutz^ 
is  based  upon  the  study  of  99  cases  of  non-puerperal  pelvic  peritonitis, 
with  13  autopsies.  The  records  of  7  of  these  cases,  6  of  which  were 
his  own  and  1  that  of  his  friend  ]\I.  Boucher,  are  in  everv  sense  com- 
plete and  perfect  histories.  These  histories  present  a  full  and  minute 
description  of  the  clinical  features  of  the  disease.  They  also  describe 
with  the  greatest  precision  the  pathological  condition  of  the  pelvic 
tissues  as  observed  after  death.  And,  lastly,  they  demonstrate  beyond 
'  Clinical  Manoirs  on  Diseases  of  Women,  New  Sydenham  Soc,  trans,  by  Meadows. 


688  PERIUTERINE  INFLAMMATION. 

cavil  the  existence  of  an  inflammation  of  the  pelvic  peritoneum,  pure 
and  simple,  sufficiently  extensive  to  destroy  life  and  uncomplicated  by 
a  trace  of  cellulitis. 

It  is  only  justice  to  Bernutz  to  say  that  his  memoirs  contain  the  fullest 
exposition  of  this  subject,  and  while,  since  his  day,  much  has  been  done 
to  confirm  what  he  has  written,  no  very  important  additions  have  been 
made  to  the  stock  of  knowledge  which  we  have  derived  from  his  inves- 
tigations. 

Referring  to  these  investigations.  Dr.  T.  Gaillard  Thomas  ^  wrote  in 
1868  :  "  Since  the  publication  of  these  views  I  have  directed  my  atten- 
tion particularly  to  this  point,  and  from  careful  observation,  both  clin- 
ical and  post-mortem,  feel  warranted  in  recording  the  conclusions  at 
which  I  have  arrived  in  the  following  propositions : 

"1.  Periuterine  cellulitis  is  very  rare  in  the  non parous  woman,  while 
pelvic  peritonitis  is  very  common. 

"  2.  A  very  large  proportion  of  the  cases  now  regarded  as  instances 
of  cellulitis  are  really  those  of  pelvic  peritonitis. 

''  3.  The  two  affections  are  eutirely  cTistinct  from  each  other,  and 
should  not  be  confounded  simply  because  they  often  complicate  each 
other.  They  may  be  compared  to  serous  and  parenchymatous  inflam- 
mation of  the  lungs,  pleurisy,  and  pneumonia.  Like  them,  they  are 
separate  and  distinct ;  like  them,  affect  different  kinds  of  structure ;  and 
like  them,  often  complicate  each  other. 

"  4.  They  may  usually  be  readily  differentiated  from  each  other,  and 
a  neglect  of  the  effort  at  such  thorough  diagnosis  is  as  reprehensible  as 
a  similar  want  of  care  in  determining  between  pericarditis  and  endo- 
carditis." 

In  1869,  Dr.  Matthews  Duncan  said:  "My  adoption  of  Bernutz's 
views  is  not  founded  on  clinical  observation  merely,  but  on  several 
post-mortem  investigations  made  by  myself  or  for  me  by  able  path- 
ologists." 

Still  more  recently.  Professors  Spiegelberg  of  Breslau  and  Fritsch  of 
Halle,  and  Drs.  Hart  and  Barbour  of  Edinburgh,  have  accepted  these 
views  and  have  written  in  elucidation  of  the  subject.  But  perhaps  the 
surgical  work  of  Mr.  Lawson  Tait  in  the  way  of  removing  diseased 
uterine  appendages  by  abdominal  section,  begun  about  twelve  or  fifteen 
vears  ag-o,  and  carried  on  with  such  wonderful  results  as  now  to  be 
familiar  to  the  entire  medical  world,  has,  more  than  all  else,  led  to  a 
clear  demonstration  and  a  general  acceptance  of  the  views  which  were 
promulgated  by  Bernutz. 

One  of  the  most  valuable  contributions  which  has  recently  been  made 
to  this  subject  is  a  paper  ^  by.  Prof.  William  M.  Polk,  read  before  the 

1  Op.  cif.,  1868,  1st  ed. 

^"Periuterine  Inflammation,"  Medical  Record,  New  York,  Sept.  18,  1886. 


I'ELVlc  riCRITONITIS.  GMO 

Socii'ty  of  Pliysiciaiis  and  l':illin|(.Mi~t-,  \\':isliiiit:toii,  I).  C'.,  June  18, 
1886.  In  this  pajx-r  a  rc<-ur»l  of"  Ki  cjl^cs  is  ollln-d  in  wliidi  alxloni- 
inal  section  wils  made  ior  tlie  rcliel"  oi"  chronic  pelvic  inllanunatinn. 
The  lesions  I'ouiul  were  sali)injj:;itis,  |)eriovaritis,  ami  pelvic  peritonitis. 
To  this  important   piil)lication   reference  will  a<rain  he  made. 

l*ATHOL<)(JV. — The  memoir  of  liernut/,  rich  in  anatomical  material, 
is  well  worth  Ciireful  study.  It  contains  a  report  of  1.3  autopsies.  After 
a  careful  studv  of  symptoms  and  ])hysical  sifi^ns  duriiiir  life,  a  physical 
exploration  of  the  pelvis  was  made  at  deatli  by  the  bimanual,  and  then 
the  abdomen  was  opened.  In  some  cases  it  is  stated  that  the  endomet- 
rium was  healthy  ;  in  others,  that  it  was  inflamed,  and  in  1  it  was 
covered  with  pus.  The  pelvic  viscera  were  covered  by  false  mem- 
branes. Adhesions  bound  them  to  each  other — the  uterus  to  the  blad- 
der or  rectum,  the  broad  ligament  to  the  sigmoid  flexure;  the  Fallopian 
tube,  bent  upon  itself,  was  adherent  to  the  posterior  wall  of  the  uterus 
or  to  Douglas's  pouch.  The  tube  was  often  adherent  to  the  ovary,  its 
fimbriated  extremity  occluded,  and  the  fimbria  destroyed.  In  9  of 
these  autopsies  one  or  both  of  the  tubes  contained  pus ;  in  2  they  con- 
tained tubercular  material.  In  1  autopsy  the  peritonitis  was  found  to 
be  due  to  cancer  of  the  ovary.  In  4  cases  the  ovaries  were  healthy. 
As  a  result  of  these  autopsies  it  may  be  said  that  the  one  constant  fea- 
ture in  pelvic  peritonitis  is  diseased  tubes — salpingitis. 

As  a  result  of  the  condition  here  described  there  is  fixation  of  the 
uterus  and  the  presence  in  the  pelvis,  at  some  point,  of  a  tumor.  The 
tumor  consists  generally  of  the  ovaries  and  tubes  folded  upon  them- 
selves, matted  together  by  exudation,  and  adherent  to  the  posterior  sur- 
face of  the  broad  ligament  or  of  the  uterus.  If  the  disease  is  chiefly 
on  one  side,  the  uterus  will  be  pushed  to  the  other  side.  In  some  cases 
the  tumor  is  behind  the  uterus,  and  pushes  it  forward  against  the  pelvic 
bone.  It  then  consists  of  an  accumulation  of  serum  or  pas  confined  in 
a  cavity,  the  walls  of  which  are  the  uterus  and  broad  ligaments  in  front, 
the  posterior  wall  of  the  pelvis  and  the  sigmoid  flexure  behind,  coils  of 
intestines  adherent  by  false  membrane  above,  and  Douglas's  pouch  and 
the  retro-uterine  shelves  l)elow. 

The  tubes  are  sometimes  like  hard  fibrous  cords,  containing  pus  in 
small  quantities,  one  of  their  fimbriated  extremities  being  occluded. 
In  other  cases  both  extremities  are  closed  and  the  tubes  greatly  dis- 
tended, forming  sausage-like  tumors  which  can  be  recognized  by  the 
bimanual. 

These  inflammatory  processes  are  oftentimes  entirely  intraperitoneal. 
In  other  cases  the  subperitoneal  connective  tissue  is  involved  to  a  slight 
extent ;  and  this  is  evidently  secondary  to  the  peritoneal  inflammation. 

Polk  in  the  paper  referred  to  says  that  in  a  large  number  of  post- 
mortem examinations  made  in  the  dead-house  of  Bellevue  Hospital 

Vol.  I. — 14 


690  PERIUTERINE  INFLAMMATION. 

"  nothing  is  more  common  than  to  find  evidences  of  peritonitis  about 
the  ends  of  the  tubes ;  and  it  is  noticeable  in  such  cases  that  the  evi-  . 
dences  of  such  inflammation  diminish  as  you  leave  the  extremities  of 
the  tubes." 

The  same  writer  adds  :  "  The  ovary  may  be  said  to  be  always  impli- 
cated in  this  peritoneal  inflammation,  the  fimbria  which  attaches  it  to 
the  tube  forming  a  ready  transmitter  of  the  process  from  the  tube ;  but 
the  extent  to  which  it  is  involved  must  depend  upon  its  proximity  to 
the  tubal  opening  and  upon  the  degree  of  the  inflammatory  process." 
Studying  the  inflammatory  process  more  minutely  as  it  occurs  in  the 
peritoneum,  it  may  be  said  that  the  serous  membrane  at  first  becomes 
hyperfemic :  its  smooth,  glistening  surface  disappears  from  loss  of  the 
epithelium,  and  very  soon  exudation  appears. 

In  the  exudation  material  connective  tissue  rapidly  forms,  and  if  but 
little  free  fluid  is  effused  to  separate  the  opposing  surfaces,  adhesion  takes 
place. 

Very  often  there  is  an  abundant  exudation  of  fluid  which  separates 
completely  the  opposing  surfaces.  In  this  fluid,  which  is  of  a  clear^ 
yellowish  appearance,  flakes  or  shreddy  masses  are  seen  floating,  and 
the  inflamed  surfaces  themselves  are  covered  with  a  yellowish  or  red- 
dish friable  substance  composed  in  the  main  of  connective  tissue  and 
known  as  pseudo-membrane. 

Resorption  of  fluid  may  now  occur  to  some  extent,  and  the  opposing 
surfaces,  coming  in  contact  here  and  there,  become  adherent.  Thus 
cavities  are  formed,  within  the  walls  of  which  fluid  still  remains,  and 
thus  peritoneal  tumors  are  produced.  These  tumors  may  undergo 
enlargement  by  the  addition  of  increased  secretion. 

In  the  severer  forms  of  peritonitis,  such  as  we  see  in  the  puerperal 
woman,  the  fluid  is  almost  from  the  beginning  purulent.  In  other 
cases  the  exudation  may  be  sero-fibrinous  for  a  time,  but  in  con- 
sequence of  some  reaccession  of  inflammation  the  cells  floating  in  the 
serum  rapidly  proliferate,  and  suppuration  results  as  a  secondary  event. 
We  have,  then,  as  clinical  facts,  adhesive  peritonitis,  sero-adhesive 
peritonitis,  and  purulent  peritonitis. 

Etiology. — The  occurrence  of  pelvic  peritonitis  in  any  given  case 

implies  a  pre-existing  lesion  of  the  uterus,  ovaries,  or  tubes.     In  many 

instances — indeed,  usually — endometrial  inflammation,  salpingitis,  and 

pelvic  peritonitis  are  simply  stages  of  one  and  the  same  morbid  process. 

The  causes  which  give  rise  to  this  disease  are — 

1.  Traumatic  Influences. — In  certain  unexplained  conditions  of  the 
sexual  organs  the  slightest  traumatism  may  produce  a  fatal  peritonitis. 
Such  a  result  has  happened  from  the  application  of  nitrate  of  silver  to 
the  cervix,  from  the  use  of  a  sponge  tent,  and  from  the  passage  of  the 
uterine  sound.     Sometimes  this  inflammation  is  traceable  to  blows  over 


PELVIC  PERirONITIS.  (ill I 

tlie  alKlDiiu'ii,  to  venereal  oxcossos,  to  the  v:i<:inal   doiielie,  to  the  mh-  of 
steiu-pc'ssaries,  and  to  siir^ieal  o|)eratioiis  on  the  eei'vix. 

2.  l^/ic  h'iilr(i)icc  of  F()r(i(/)i  ''^vf>sfaiiccs  inio  the  IMr'ir  ('(n-i/i/. — Intra- 
uterine injei'tions  may  enter  the  peritoneum  thi-ougli  the  tubes  wlien  the 
eer\i.\  has  not  Ween  well  dilated,  and  they  will  be  quite  sure  to  produce 
peritonitis.  The  sami'  result  will  follow  the  rupture  into  the  peritoneum 
of  an  abscess  of  the  ovary'  or  of  an  ovarian  eyst,  or  any  pelvic  abscess, 
rupture  of  a  jnosalpinx,  of  a  tubal  pregnancy,  or  some  one  of  the 
branches  of  the  ovarian   venous  pU'xns. 

3.  ^^r^^sfrl(al  Di'<or<h'rs. — Of  tiie  99  cases  which  formed  the  basis  of 
the  nuMuoir  of  M.  Bernutz,  20  were  set  down  to  disturbances  of  the 
menstrual  function.  The  circumstances  under  which  menstrual  pelvic 
peritonitis  occurred  were  as  follows:  lu  3  cases  of  incomplete  menstru- 
ation no  cause  was  apparent ;  twice  it  occurred  after  severe  dysmenor- 
rhfeal  pains ;  fifteen  times  after  sudden  suppression.  Of  these  15  cases, 
the  cause  of  the  sui)pressi()n  in  9  was  cold  ;  severe  mental  emotion  in  3  ; 
a  speculum  examination  in  1  ;  cauterization  of  the  cervix  in  1 ;  frequent 
sexual  intercourse  during  menstruation  in  1. 

I  have  frequently  ol)scrved  pelvic  peritonitis  in  washerwomen,  who 
stand  much  with  their  feet  in  the  wet,  and  in  prostitutes  as  a  result  of 
the  application  of  cold  water  to  the  genitals  during  menstruation  for  the 
purpose  of  stoppings  the  How  and  thereby  enabling  them  to  ply  their 
vocation.  The  eifect  of  cold  in  both  instances  is  probably  to  first 
induce  an  endometritis,  which  deranges  the  menstrual  function. 

4.  Gonorrhoea. — There  were  28  out  of  Beruutz's  cases  attributable  to 
gonorrhoea.  This  large  proportion,  he  says,  was  due  in  part  to  the  social 
condition  of  the  women  who  were  admitted  to  the  Lourcine,  and  in  part 
to  some  peculiarities  in  the  management  of  the  hospital.  In  his  cases 
the  peritonitis  never  appeared  before  the  eighth  day  of  the  disease, 
rarely  before  the  fourteenth,  frequently  at  the  end  of  the  month,  cor- 
responding to  the  menstrual  return.  It  was  the  result  of  a  gonorrhoeal 
endometritis  extending  by  continuity  of  tissue  along  the  Fallopian  tubes 
to  the  peritoneum. 

Noeggerath  has  called  attention  to  the  pernicious  influence  of  "  latent 
gonorrhoea  in  the  male."  In  this  form  the  gonorrhoeal  inflammation  is 
supposed  to  have  been  long  cured,  but  there  exists  in  reality  a  granular 
inflammation  of  the  urethra  at  some  one  point  producing  scarcely  anv 
ap])reciable  discharge  or  other  symptoms.  Proper  exploration  of  the 
urethra  reveals  a  stricture  of    large  calibre.     This  condition   I  have 

'  Abscess  of  the  ovary  in  the  non-puerperal  woman  is  of  nniisiial  occurrence,  but 
well-marked  histories  are  narrated  by  Mr.  J.  C.  Ciillinsrworth  and  Mr.  Lawson  Tait. 
The  abscess  begins  by  suppuration  of  separate  follicles;  these  subsequently  coalesce, 
and  form  an  abscess  of  the  entire  gland.  Rupture  of  such  an  accumulation  would 
cause  a  rapidly  fatal  peritonitis  iTait  on  /)('.s.  of  the  Omries,  4th  ed.,  p.  127 j. 


692  PERIUTERINE  INFLAMMATION. 

repeatedly  known  to  produce  a  vaginitis,  endometritis,  and  salpingitis 
very  soon  after  marriage,  when  the  cause  of  trouble  was  not  suspected 
by  either  husband  or  wife. 

5.  Parturition,  Abortion. — Pelvic  peritonitis  often  follows  parturi- 
tion, and  its  occurrence  is  frequently  associated  with  a  history  of 
repeated  abortions.  In  many  of  these  cases  there  will  be  found  a 
history  of  endometritis  and  salpingitis  antedating  the  pregnancy ;  and 
during  the  period  of  confinement  there  is  observed  for  the  first  time 
an  extension  of  inflammation  from  the  endometrium  to  the  pelvic 
peritoneum. 

Clinical  observation  leads  me  to  believe  that  repeated  abortions  are 
often  the  result  of  au  endometritis,  which  probably  operates  in  their 
production  by  imjaairing  the  integrity  of  the  fcetal  attachments.  Dur- 
ing the  abortion,  from  some  inappreciable  cause,  the  endometrial  inflam- 
mation extends  along  the  tubes  to  the  peritoneum.  The  parturient  pro- 
cesses seem  to  furnish  the  opportunity  for  propagation  of  an  antecedent 
inflammation. 

This  association  of  pelvic  peritonitis  with  the  puerperal  state  and 
abortion  was  observed  by  Beruutz.  Of  his  cases  there  were  43  follow- 
ing the  parturient  act ;  35  of  these  occurred  after  delivery  at  terra,  and 
8  after  abortion.  In  many  of  these  cases  there  was  admission  to  the 
blood  of  poisonous  material  through  lacerations  of  the  uterine  canal. 
In  others  there  was  probably  an  endometritis,  induced  by  special  excit- 
ing causes,  such  as  venereal  excess  prior  to  and  causing  the  abortion, 
exertion  too  soon  after  labor,  or  cold. 

Before  the  introduction  of  antiseptic  methods  rapidly  fatal  peritonitis 
was  often  observed  from  septic  poisoning. 

Polk  in  his  paper  remarks :  "An  item  of  interest  in  many  of  the 
cases  is  the  appearance  of  abortions  and  miscarriages  as  etiological 
factors." 

After  childbirth  inflammation  of  the  pelvic  cellular  tissue  is  the 
lesion  most  commonly  observed.  It,  as  well  as  the  accompanying 
peritonitis,  is  of  a  septic  character.  According  to  Winckel,^  who  has 
made  many  autopsies,  the  trouble  begins  as  a  catarrhal  endometritis, 
and  extends  through  the  intermuscular  connective  tissue  of  the  uterus 
to  the  parametric  tissue,  and  thence  to  the  peritoneum.  He  says  in 
these  cases  it  is  2'are  for  the  inflammation  to  spread  through  the 
tubes. 

6.  Tubercle,  Cancer. — Tubercular  pelvic  peritonitis  may  supervene 
slowly,  as  a  diathetic  manifestation,  upon  pre-existing  pulmonary  dis- 
ease, and  scarcely  attract  attention  during  life.  It  may  develop  simul- 
taneously with  the  pulmonary  disease,  it  may  precede  it,  or  it  may  run 
its  course  without  any  pulmonary  complications.     Usually,  tubercular 

^  On  Childbirth,  translated  by  Chadwick,  1876. 


ph'iA'fc  rr.iurosiTis.  ok;; 

peritonitis  has  liccii  picccdcd,  at  sumc  [Miiod  ninrc  or  |cs>  rciiiolf,  1)V  an 
attack  of  sini|)lr  pilvic  jKTitonitis. 

I'lu'  canccroiis  fofni  of  llic  disease  is  (lie  result  of  ext<.'nsi(»n  <•("  nle- 
rine  cancer  t(t  the  |)aranietric  tissue,  and  thence  to  the  peritonenni. 

7.  Ctiriitc  F/c.rioiis  (iiifl  \'<rsi()iis. — An  enlari;-e(l  and  (lisj)la<'ed  nterns, 
l»y  dointi;  injury  to  the  neighl)orin<r  peritoneiini,  may  give  rise  to  a  mild 
lulhosive  j)eritouitis.  So  also  does  a  roughened,  enlarged,  ami  di-placed 
ovary. 

<S.  Piii'ic  ('c/lii/iti.-<. — Pelvic  peritonitis  very  <»t'ten — indeed,  generally 
— exists  wlierever  there  is  a  pelvic  cellulitis.  The  anatomical  connections 
hetwecn  the  two  structures  are  very  intimate,  and  hoth  inflammations 
are  the  result  of  a  common  cause.  I  do  not  think  it  strictly  correct  to 
say  that  the  pelvic  cellulitis  is  the  cause  of  the  peritonitis. 

While  considering  the  influence  of  all  the  varying  causes  which  have 
been  enumerated,  it  is  important  to  remember  a  fact  which  is  clearly 
established  by  the  auto[)sies  of  Bernutz;  that  is,  the  almost  constant 
association  of  diseased  FallojMan  tubes  Avitli  ])elvic  peritonitis,  and  the 
frequent  existence  of  pelvic  peritonitis  unassociated  with  pelvic  cellu- 
litis. Abdominal  sections  and  post-mortem  observations  by  Polk  and 
others  substantiate  the  truth  of  these  conclusions. 

Symptomatology. — Pain,  severe  and  paroxysmal,  is  the  most  prom- 
inent and  the  most  constant  symptom  of  acute  pelvic  peritonitis.  This 
pain,  located  in  the  hypogastric  and  iliac  regions,  may  come  on  sud- 
denly and  without  premonitory  warnings,  or  it  may  be  preceded  for 
days  by  feelings  of  weight  and  pelvic  discomfort.  The  slightest  move- 
ment of  the  body  intensifies  the  patient's  suifering.  Micturition  and 
defecation  become  painful.  Great  anxietj'  is  depicted  in  the  counte- 
nance, dark  circles  are  seen  beneath  the  eyes,  and  the  patient  clamors 
for  relief.  The  dorsal  decubitus,  with  the  thighs  flexed,  is  the  position 
generally  assumed.  The  abdomen  in  its  lowest  part  is  sensitive  to  the 
lightest  touch.  It  is  somewhat  swollen,  and  is  resistant  to  pressure,  l)ut 
in  the  beginning  of  the  attack,  before  exudation  occurs,  it  is  resonant 
on  percussion.  In  most  of  th^  cases  gastric  symptoms  constitute  a 
marked  feature,  and  nausea  and  vomiting  occasion  much  distress.  The 
bowels  are  usually  constipated,  though  occasionally  there  is  diarrhcea. 
The  pulse  is  small  and  frequent  or  else  feeble  and  depressed,  not  reach- 
ing 100.  The  temperature  in  many  severe  cases  will  reach  105°  ;  in 
most  cases  its  range  is  moderate,  yet,  as  will  presently  be  shown,  there 
are  many  exceptions  to  this  rule. 

But  the  manner  of  invasion  of  pelvic  peritonitis  is  variable.  In 
some  instances  it  is  abrupt  and  well  marked,  being  introduced  by  a 
chill.  At  other  times  it  approaches  slowly,  there  is  no  distinct  rigor, 
and  several  davs  elapse  bef<»re  its  character  is  established.  These  cases 
are  of  the  subacute  or  chronic  form,  and  their  real   nature  may  at  first 


694  PEBIVTERINE  INFLAMMATION. 

be  easily  overlooked.  Instead  of  well-defined  pain,  there  will  be  only- 
soreness  through  the  pelvic  region.  The  patient  perhaps  does  not  go  to 
bed,  but  complains  of  languor  and  debility,  and  there  is  a  slight  febrile 
movement  in  the  evening. 

One  of  the  earliest  symptoms  of  this  disease  is  a  moderate  meti'or- 
rhagia. 

These  are  the  conspicuous  features  of  j)elvic  peritonitis.  It  should, 
however,  be  borne  in  mind  that  the  symptoms  will  differ  very  greatly 
in  different  cases.  This  will  not  be  a  matter  of  surprise  when  we 
remember  that  a  variety  of  pathological  conditions  underlie  pelvic 
peritonitis,  or,  in  other  words,  that  the  peritoneal  inflammation  is  in 
itself  only  a  symptom  of  several  different  morbid  states. 

Braxton  Hicks  ^  has  stated  that  in  some  malignant  cases  of  sep- 
tic origin  all  the  usual  symptoms  are  wanting,  "  the  rapid  pulse 
and  pyrexia,  coupled  with  a  peculiar  expression  of  countenance,  being 
almost  our  only  guide,"  The  abdomen  in  these  cases  is  filled  with  a 
purulent  fluid,  and  vaginal  examination  discovers  none  of  the  usual 
physical  signs. 

In  reference  to  the  symptom  of  pain,  which  is  so  characteristic  of 
peritoneal  inflammation  generally,  it  may  be  stated  that  sometimes,  even 
in  extensive  suppurating  peritonitis,  there  is  no  pain  whatever.  Bernutz 
emphasizes  this  fact,  and  Duncan^  says:  "I  might  adduce  cases  of 
gonorrhoeal  ovaritis,  commencing  in  healthy  girls  and  ending  in  the 
fusion  of  all  the  parts  in  the  pelvis  into  a  solid,  immovable  mass,  with- 
out the  patient  losing  a  cheerful,  and  even  gay,  visage,  or  making  any 
great  complaint  of  pain,  unless  interrogated  closely,  and  then  alleging 
the  chief  suffering  to  be  from  irritable  bladder." 

The  range  of  the  thermometer  is  also  a  feature  which  presents  great 
variations  from  the  course  described.  Although  very  high  temperatures 
are  often  seen  in  peritonitis,  the  thermometer  may  be  scarcely  above 
normal,  or  even  below  it,  in  the  gravest  cases.  "  Subnormal  temper- 
atures are  especially  common  in  peritonitis,  and  always  suspicious: 
death  may  follow  these  closely.  High  and  rising  temperatures  do 
not  add,  -per  se,  arguments  for  an  unfavorable  termination,  although 
adding  another  dangerous  element  to  the  case.  It  is  not  so  much  the 
actual  height  as  its  constancy  which  must  be  feared,  as  must  also  great 
and  irregular  fluctuations  between  very  high  and  very  low  temperatures, 
similar  to  pysemia,  common  in  endocarditis,  less  frequent  in  inflamma- 
tions of  the  pericardium,  pleura,  and  peritoneum  :  these  are  always 
highly  dangerous."^  Very  serious  cases  with  a  temperature  never 
2'oina-  above  100°  durins;  their  entire  course  are  of  common  occurrence. 

The  progress  of  the  disease  varies  greatly,  and  no  precise  hmit  can  be 

1  Quain's  Diet,  of  Medicine,  6th  ed.,  "  Pelvic  Peritonitis."  ^  Op.  cit.,  p.  78. 

^  Medical  Thermometry,  Wimderlich,  Seguin,  p.  167. 


/ 'EL  \ IC  PKRITOMTIS.  (J ! ) . j 

assi«i;iu'<l  to  it>  iliiialion.  1 1' the  iiill;iiiiiii:itii»ii  Ik- a  >iiii|)Ic  ;Klli(si\<- iicri- 
toiiitis,  the  sviiipliiiii-  may  attract  hut  little  attention,  and  no  knnwledtre 
l)e  had  of  the  atla<'k  diuini:;  life.  Should  the  patient  die  IVoni  .some 
other  cause,  adiiesions  attest  its  oeeiii-rence.  If  tiie  jjoritoiiitis  he  due  to 
rupture  of  a  tuhal  ])re<inancy  ahout  the  sixth  oreii^hth  week  of  gestation, 
all  inrianiniation  may  ilisappear  in  lour  or  live  weeks,  the  ovum  heeome 
encysted,  and  eonvalescenee  be  slowly  established. 

ri'  the  morbid  eonditif)n  bi"  diseased  tubes,  with  ])erhaj»s  hvdro-  or 
j)yosalj)inx,  no  limit  can  be  Hxed  to  the  duration  of  the  consequent 
peritonitis.  It  eontiiuies  indeHnitely  with  frequent  exacerbations,  and 
induces  a  condition  of  confirmed  invalidism  of  the  most  pitiable  kind. 
The  earliest  period  at  which  an  attack  of  the  sero-adhesive  variety 
may  be  expected  to  terminate  is  four  oi-  live  weeks,  and  it  will  often 
continue  much   longer. 

One  characteristic  feature  of  the  disease  which  has  not  yet  been  men- 
tioned is  a  tendency  to  exacerbations.  The  patient  may  seem  to  be  ap- 
proaching convalescence,  when  all  at  once,  without  appreciable  provo- 
cation, there  will  be  a  return  of  pain,  a  rise  of  temperature,  and  an 
increa.se  of  the  exudation  in  the  pelvis.  The  cause  of  this  sudden 
change  may  be  some  physical  exertion  on  the  part  of  the  patient,  or 
else  that  determination  of  blood  to  the  pelvic  organs  Avhich  precedes 
menstruation.  A^ery  often  the  exacerbation  will  be  inexplicable  except 
upiMi  the  view  suggested  by  ]Mr.  Lawson  Tait,  that  there  has  been  ruj>- 
ture  of  an  occluded  and  distended  tube,  or  that  of  Matthews  Duncan, 
the  rupture  of  small  follicular  dropsies  in  the  ovarv.  Generallv,  tliese 
exacerbations  are  induced  by  the  escape  of  the  contents  of  the  tubes  into 
the  pelvic  cavity. 

In  very  protracted  cases  there  will  usually  Ijc  found  purulent  collec- 
tions at  some  point  in  the  pelvis.  The  occurrence  of  suppuration  will 
sometimes,  but  by  nc^  meiius  alwavs,  be  indicated  bv  rigors,  fevei^  of 
the  hectic  type,  and  night-sweats.  After  pus  fjrms,  unless  it  be  com- 
pletely evacuated  by  surgical  or  natural  means,  a  cachectic  condition 
arises  which  sooner  or  later  gives  rise  to  certain  secondarv  affections  of 
grave  importance.  Bernutz  has  placed  these  in  a  very  clear  light  before 
us,  and  they  are  familiar  to  all  who  have  studied  this  disease. 

The  first  of  these  secondary  affections  is  an  extension  of  inflamma- 
tion through  continuity  of  tissue  to  the  abdominal  ])eritoneum.  The 
second  is  a  catarrhal  and  often  ulcerative  inflammation  of  the  mucous 
membrane  of  the  entire  intestinal  tract,  giving  rise  to  an  intractable 
diarrh(fa.  About  the  time  this  affection  arises  a  third  is  often  added, 
to  w^hich  Andral  has  previously  directed  attention  ;  that  is,  a  form  of 
broncho-pneumonia  with  profuse  jjurulcnt  expectoration.  The  condition 
of  thi^  patient  now  closelv  resembles  that  of  one  in  an  advanced  staire 
of  jiulmonary  con-umjnion. 


696  PERIUTERINE  INFLAMMATION. 

Chronic  Pelvic  Peritonitis. — There  is  much  of  truth  in  the  remark 
of  Bernutz,  that  in  chronic  peritonitis  "  one  only  of  the  elements  of 
the  affection  is  really  chronic — viz.  the  uterine,  the  tubal,  or  the  ova- 
rian affection  which  originated  the  peritonitis,  and  which,  with  each 
aggravation  of  the  malady,  sets  up  fresh  peritoneal  mischief,  thereby 
modifying  the  condition  of  the  periuterine  swelling." 

It  is  very  probable  that  many  of  the  cases  of  chronic  or  recurrent 
pelvic  peritonitis  owe  their  long  continuance  to  the  escape  into  the  peri- 
toneum of  inflammatory  products  from  a  distended  tube.  This  is  espe- 
cially true  of  gonorrhoeal  cases. 

While  the  chronic  form  is  often  the  result  of  an  inflammation  which 
was  at  first  acute,  very  many  cases  are  essentially  chronic  from  the 
beginning,  the  patient  being  for  long  more  or  less  of  an  invalid,  and 
not  taking  to  her  bed  except  at  the  menstrual  periods,  when  she  is  then 
forced  to  do  so  from  pain  and  slight  febrile  movement.  In  other  cases 
the  chronicity  appears  to  be  due  to  the  influence  of  some  previously- 
existing  constitutional  taint,  such  as  syphilis  or  tuberculosis. 

M.  Aran  said,^  ''At  least  two-thirds  of  the  women  who  suffer  from 
chronic  pelvic  peritonitis  are  the  subjects  of  tuberculosis." 

Physical  Signs. — In  many  cases  an  exploration  of  the  pelvis  will 
reveal  to  the  examining  finger  great  tenderness  over  the  entire  pelvic 
roof  and  resistance  upon  pressure  on  all  sides  of  the  uterus.  At  the 
same  time,  the  vaginal  culs-de-sac  are  clear;  no  tumor  can  be  any- 
where felt;  the  inflammation  is  not  localized.  The  position  of  the 
uterus  is  that  which  it  occupied  in  health,  and  any  attempt  to  change 
it  produces  pain.  Fixation  of  the  uterus  is  absolute — a  degree  not 
attained  in  uncomplicated  pelvic  cellulitis. 

In  other  cases  to  the  physical  signs  just  enumerated  that  of  tumor 
will  be  added.  This  tumor  is  close  to  the  uterus,  and  yet  distinct  from 
it,  the  two  being  separated  by  a  groove.  The  tumor  is  composed  of 
false  membranes  binding  together  portions  of  the  pelvic  viscera,  to 
which  a  pyosalpinx  is  often  added ;  or  it  may  consist  of  an  encysted 
serous  or  purulent  effusion  in  addition  to  the  above. 

This  tumor  has  many  of  the  signs  of  a  phlegmon,  but  may  usually 
be  distinguished  from  it  by  the  following  characteristics : 

I.  Its  Position. — (a)  It  occupies  the  latero-posterior  part  of  the 
uterine  circumference,  being  situated  in  Douglas's  pouch,  and  extends 
at  the  same  time  into  one  of  the  retro-ovarian  shelves.  It  then  neces- 
sarily pushes  the  uterus  and  one  broad  ligament  forward  in  proximity 
to  the  pelvic  bone. 

(6)  It  may  be  an  encysted  serous  or  purulent  effusion,  having  for  its 
lower  and  lateral  boundaries  the  walls  of  Douglas's  pouch.  It  will 
then  carry  the  uterus  and  both  broad  ligaments  upward  and  forward 

^  Legons  diniques  sur  les  Maladies  de  V  Uterus,  p.  716. 


VELVK'  I'lJ'JTOSITIS.  fi07 

a<i;aiiist  the  [nihic  hone,  ami  tlu;  aiiatuiuical  outlines  of  this  poiirli  will 
he  ck'arlv  (li'liiicd  on  tlic  postt'riur  wall  of  the  vuf^ina.  The  eiitin; 
j)()sterior  halt"  of  the  pilx  is  i<  then  o((ii|)i((l  hy  the  prodiici-.  (.f  iiiflaiii- 
niation. 

((')  Another  |oi-ii»  ot"  tumor  is  a  small,  wcll-ddimd  swcUin}^  the  size 
ot"  a  |)ii!,('oirs  e<2:«:;  or  lar^t-r,  occupying  one  of  the  lateral  culs-de-sao 
situatetl  hehind  the  hroad  ligament,  separated  from  the  side  of  the 
uterus  hy  a  groove,  and  extending;  to  ahout  the  level  of  the  fundus. 
Sueh  a  tumor  may  consist  (»f  a  small  serous  or  purulent  eolleetion 
enclosed  hy  false  inemhrancs  extendino;  from  the  si«:;moid  flexure  to 
tlie  left  hroad  liirament,  the  ovary  and  Fallopian  tube  forminj^  part  of 
the  mass. 

A  tumor  of  any  size  situated  in  the  utero-vesical  pouch  is  very  rare, 
because  of  the  shallowness  of  this  pouch ;  hence  we  scarcely  look  for  a 
peritoneal  accumulation  in  front  of  the  uterus. 

II.  The  Changeable  Nature  of  the  Tumor. — Bernutz  called  attention 
to  its  disappearance,  and  reappearance  in  perhaps  a  different  situation, 
at  short  intervals.  While  I  have  repeatedly  observed  this,  it  has  been 
particularly  noticeable  in  chronic  cases  which  I  would  see  at  intervals 
of  one  or  two  weeks.  The  change  in  position  was  often  so  marked  that 
I  might  have  douI)ted  the  correctness  of  the  previous  examination  had 
I  not  made  a  careful  record  of  the  exact  size  and  location  of  the 
tumor. 

III.  Peritoneal  Tumors  are  Extremely  Sensitive  to  the  Touch. — As  a 
rule,  they  rarely  extend  above  the  superior  limits  of  the  pelvis,  and 
can  be  explored  only  through  the  vagina.  In  cases  of  long  standing, 
however,  the  inflammation  may  gradually  extend  beyond  the  limits  of 
the  pelvis,  and  the  tumor  then  become  abdominal.  Occasionally,  I 
have  seen  abdominal  tumor  form  in  recent  cases  when  there  was  no 
ground  for  the  suspicion  of  haematocele  or  rupture  of  an  extra-uterine 
pregnancy. 

DiFFEREXTiAL  DIAGNOSIS. — The  diseases  most  likely  to  be  con- 
founded with  pelvic  peritonitis  are  pelvic  cellulitis  and  intraperitoneal 
hiematocele.  That  from  which  its  differentiation  is  most  difficult  and 
most  frequently  called  for  is  pelvic  cellulitis.  In  some  cases  this  dif- 
ferentiation is  impossible:  the  two  diseases  coexist,  all  the  structures  of 
the  pelvis  are  involved,  and  the  only  diagnosis  possible  is  pelvic  inflam- 
mation. In  other  cases  the  diagnosis  can  be  satisfactorily  made.  It 
should  always  be  attempted,  not  only  on  the  ground  of  scientific  accu- 
racy in  the  study  of  disease,  but  because  of  its  practical  bearing  upon 
prognosis  and  treatment.  A  careful  study  of  the  ca^  in  all  its  aspects, 
and  an  intimate  acquaintance  with  the  anatomy  of  the  pelvic  perito- 
neum and  cellular  tissue,  by  enabling  the  observer  to  locate  preciselv 
the  exudation,  will  often  lead  to  the  formation  of  a  correct  opinion. 


698  PERIUTERINE  INFLAMMATION. 

The  etiology  is  of  the  first  importance  as  an  aid  to  diagnosis.  Cel- 
lulitis is  an  inflammation  essentially  acute  in  its  character,  generally 
associated  with  a  well-marked  septicemia,  and  apt  to  eventuate  rapidly 
in  suppuration.  It  commonly  occurs  after  labor  or  abortion,  and  may 
follow  gynecological  operations  upon  the  cervix.  In  this  form  it  is  also 
associated  with  salpingitis  and  pelvic  peritonitis. 

But  pelvic  peritonitis  may  also  occur  as  a  septic  inflammation,  and 
terminate  rapidly  in  death  uncomplicated  with  cellulitis.  Bouchut's 
case,  occurring  after  menstrual  suppression  from  cold  (reported  by 
Bernutz,  Case  III.),  was  evidently  of  this  character. 

Dr.  H.  C.  Coe,  the  pathologist  to  the  Woman's  Hospital  of  the  State 
of  New  York,  in  a  paper  entitled  "  The  Exaggerated  Importance  of 
Minor  Pelvic  Inflammations," '  makes  the  following  statement :  "  Of 
half  a  dozen  fatal  cases  of  hystero-trachelorrhaphy  and  incision  of  the 
cervix,  in  which  I  have  enjoyed  the  rare  opportunity  of  studying  care- 
fully the  sequences,  in  every  instance  the  cause  of  death  was  acute  dif- 
fuse peritonitis.  The  inflammation  could  be  traced  straight  up  from  the 
wound  along  the  mucous  membrane  of  the  uterus  as  an  endometritis, 
along  the  tubes  as  a  pyosalpinx,  and  then  to  the  peritoneal  cavity.  In 
none  of  these  cases  was  there  any  evidence  of  acute  cellulitis,  although 
old  cicatrices  were  not  wanting." 

Peritonitis  usually,  however,  is  not  of  a  septic  character.  The  causes 
which  give  rise  to  it  are  well  known  and  have  already  been  enumerated. 
It  is  generally  the  result  of  disease  beginning  in  the  vagina  or  uterus, 
giving  rise  to  an  endometritis,  and  spreading  rapidly  or  slowly,  in  an 
acute  or  chronic  form,  by  continuity  of  tissue  as  a  salpingitis,  until  the 
peritoneum  is  reached. 

The  importance  of  differentiating  peritonitis  from  cellulitis  does  not 
attach  to  those  pelvic  inflammations  which  are  associated  with  a  M^ell- 
marked  septicsemia,  for  here  both  structures  are  usually  involved;  but  to 
the  more  chronic  forms,  and  to  those  attacks  of  simple  acute  inflamma- 
tion of  which  the  memoir  of  Bernutz  affords  so  many  examples. 

The  chronic  forms  to  which  I  refer  have  been  fully  described  by 
Polk  in  the  paper  spoken  of.  They  have  also  been  discussed  by 
Coe  as  "  minor  pelvic  inflammations,"  and  by  Dr.  Frank  P.  Foster^ 
as  "lesser  pelvic  inflammations."  They  are  characterized  by  inflam- 
matory masses  in  the  pelvic  roof,  on  the  sides  of  or  posterior  to  the 
uterus,  by  the  presence  of  circumscribed  areas  of  periuterine  inflam- 
mation ;  by  areas  of  "  induration,"  "  resistance,"  or  apparent  "  thick- 
ening of  the  tisues "  situated  most  commonly  about  the  base  of  the 
broad  ligaments  or  near  the  utero-sacral  ligaments ;  and  are  painful 
on  pressure. 

By  some,  these  localized  inflammations  have  been  regarded  as  chronic 

'  The  New  York  Med.  Journ.,  May  15,  1886.  "^  Ibid.,  Jan.,  1881. 


riCLVfC  PERITONITIS.  i\\)\) 

cellulitis,  hy  otlicrs  ;is  |)crii()iii(is.  ICmiiict  '  laid  jrrcjit  -tress  upon  tlicm, 
aiwl  Ujxiii  tlu'  iiii|n>rtaiicc  (tf  their  feednnition,  aixl  he  has  i-e<;anle(l  theni 
as  the  result  (»r  a  limited  cellulitis,  lie  deserihed  them  as  jjcing  most 
tre(jiiently  f'oiuid  uiidiT  tin'  pn.-terior  I'aee  of  the  left  hroad  li'rauieut 
in  elose  pi'oximity  to  the  cervix  or  cxteiidiiiu  hackward  alon<:;  the  rjo-ht 
utero-sacral  liuament.  He  says:  "  If  thickening  ut  any  point  can  he 
detected,  or  an  unusual  amount  of  pain  he  elicited  by  j)reH.sure  of  the 
fiiiiicr,  it  will  l)e  inadmissil)le  t(j  institute  any  surjrical  |)rocedin-(,'  or  to 
attempt  to  reduce  the  uterus  if  it  is  retroverted,  to  introduce  the  sound, 
or  to  make  any  application  with  in  the  uterine  canal." 

In  many  cases  these  tender  j)oint.s  or  localized  areas  of  inflammation 
are  easily  overlooked  in  examining  the  pelvis,  for  they  are  not  at  the 
base  of  the  broad  ligament,  but  are  high  up  and  require  a  far-reaching 
finger  to  detect  them.  The  opinion  that  these  areas  are  the  result  of 
cellulitis  is  held  chiefly  by  those  who  have  been  guided  bv  clinical 
observation  alone. 

Since  Emmet's  work  was  written  the  results  of  abdominal  section,  so 
extensively  practised  during  the  past  two  years  in  Europe  and  America, 
have  contributed  largely  to  the  elucidation  of  this  subject.  In  fact,  they 
have  demonstrated  that  the  exudations  here  described,  and  for  so  lons" 
considered  as  cellulitic  in  character,  are  in  reality  the  products  of  a 
peritoneal  inflammation.  Thus,  Polk  in  the  paper  referred  to  presents 
a  record  of  cases  "  in  which  the  symptoms  and  signs  present  were  those 
of  pelvic  cellulitis  and  pelvic  peritonitis,  but  in  Mhich  abdominal  sec- 
tion showed  salpingitis,  periovaritis,  and  peritonitis.  In  two  of  the 
cases  there  Avas  slight  oedematous  swelling  of  the  cellular  tissue  in  the 
broad  ligament  just  beneath  the  spot  at  which  an  inflamed  tube  had 
rested ;  in  the  remainder  the  most  careful  examination  failed  to  detect 
the  slightest  induration  or  swelling  in  any  part  of  the  cellular  tissue 
that  lay  about  the  uterus  or  between  the  peritoneal  lavers  of  the 
ligaments," 

In  these  cases  the  bimanual  exploration  of  the  pelvic  organs  was 
employed  before  and  after  the  operation.  After  removing  the  diseased 
uterine  appendages,  the  swelling  could  not  be  found  in  a  single  case. 
This  is  testimony  of  the  most  positive  character. 

The  same  conclusions  in  regard  to  the  nature  of  these  swell inir'=i  have 
been  reached  by  those  Avho  have  had  opportunity  to  make  post-mortem 
examinations.  Thus,  Coe,  in  the  paper  referred  to,  states  :  "  Peritonitis 
is  certainly  the  most  prominent  element  in  most  of  these  cases,  as  far  as 
the  post-mortem  ap})earances  afford  any  light."  In  a  different  connec- 
tion he  says:  "By  far  the  greatest  number  of  these  indurations  are 
situated  high  up  in  the  broad  ligaments,  and  consist  of  cicatricial 
masses  mostly  confined  to  the  peritoneum,  of  tubes  or  ovaries  sur- 
*  Principles  and  Prac.  of  Gynecolo'jy,  1 884. 


700  PERIUTERINE  INFLAMMATION. 

rounded  by  old  adhesions,  or  occasionally  of  an  imprisoned  knuckle 
of  intestine. 

"  The  thickening  of  the  utero-sacral  ligaments  so  frequently  alluded 
to  in  works  on  gynecology  has,  when  carefully  dissected  out,  proved  in 
my  experience  to  be  due  not  so  much  to  a  disease  of  the  connective  tissue 
of  these  ligaments  as  to  a  cicatricial  condition  of  the  peritoneum  cover- 
ing them."  .  ..."  I  confess  that  I  have  rarely  (perhaps  half  a  do2en 
times)  found  such  thickenings  in  the  cadaver  which  could  be  referred  to 
a  pure  and  straightforward  cellulitis  or  inflammation  of  the  connective 
tissue;  and  this,  too,  where  I  have  recognized  by  the  vaginal  touch 
{before  and  after  deathj  what  seemed  to  be  an  induration,  a  distinct 
band  extending  outward  from  a  deep  laceration  of  the  cervix,  or  a  con- 
dition of  tension  in  or  above  one  lateral  cul-de-sac  which  did  not  exist 
on  the  opposite  side." 

Polk  makes  the  following  statements :  "  In  a  large  number  of  post- 
mortem examinations  made  in  the  dead-house  of  Bellevue  Hospital  it 
is  noticed  that,  excepting  those  patients  who  have  died  of  septicaemia, 
it  is  the  rarest  thing  to  find  pelvic  cellulitis,  unless  the  cellulitis  be 
clearly  secondary  to  a  previous  inflammation  of  the  pelvic  peritoneum." 

This  evidence  is  adduced  here  in  full  in  order  to  show  that  the  common, 
every-day  form  of  chronic  pelvic  inflammation  which  attracts  the  atten- 
tion of  the  gynecologist,  as  well  as  the  simple  acute  pelvic  inflammation 
which  is  met  with  unconnected  with  septicoemia,  is  pelvic  peritonitis  asso- 
ciated with  diseased,  appendages,  and  is  not  pelvic  cellulitis. 

Intraperitoneal  hfematocele  will  be  characterized  by  the  following 
history :  Shock,  anagmia,  pain,  and  vomiting  are  the  symptoms  which, 
all  of  a  sudden,  announce  the  occurrence  of  hsematocele  if  the  hemor- 
rhage be  copious.  Then,  should  the  bleeding  cease  and  reaction  occur, 
coagulation  of  the  blood  begins  and  peritonitis  ensues.  The  effusion 
being  walled  in  by  lymph,  a  tumor  is  formed  which  at  first  is  soft  and 
fluctuating.  As  more  lymph  is  effused  and  the  coagulum  becomes 
firm,  the  tumor  grows  hard  and  resistant.  This  tumor,  like  that  in 
pelvic  peritonitis,  is  usually  retro-uterine,  and  pushes  the  uterus 
upward  and  forward  against  the  pubes.  Unlike  recent  peritonitis, 
there  is  usually  in  hsematocele  an  abdominal  tumor. 

But  hsematocele  often  fails  to  make  itself  known  by  rational  symp- 
toms. Of  28  cases  reported  by  Bernutz,  the  diagnosis  being  confirmed 
in  20  either  by  puncture  or  autopsy,  symptoms  of  hemorrhage  were 
present  in  8  only.  Symptoms  indicating  syncope  or  collapse  are  very 
often  absent  even  in  large  hsematoceles. 

In  these  cases,  inasmuch  as  the  physical  signs  are  identical  with  those 
of  peritonitis,  a  diagnosis  may  not  be  possible  unless  suppuration  occurs. 
When  it  becomes  necessary  to  open  the  abscess,  the  discharge  of  coagula 
with  the  pus  will  then  reveal  the  true  nature  of  the  attack. 


PELVIC  i'/:i:iTf).\iTis.  701 

Occasionally  liu'inaiitcflc  tolldws  iipun  pi  ritoiiitis,  jls  .shown  hv 
Viivliow,  the  litiM()rrliai;f  hciiitr  <lii<'  to  the  ni|)tiir('  of  new  vesseisj 
in   the  lalse  nicinhrancs. 

Thougli  it  l)c  a  digression  fioiii  the  subject  we  are  considering,  yet, 
as  strictly  relate<l  to  it,  mention  may  here  he  made  of  a  symj)tom  which 
has  lont;  l)een  known  as  e(»lica  seortorum.  It  is  an  interesting  incident 
in  the  history  of  jx-lvie  peritonitis,  and  when  [)resent  may  serve  to 
make  clear  a  diagnosis  which  without   it  might  be  oljscurc. 

This  is  an  agoni/ing  pain  on  one  side  of,  and  deep  down  in,  the 
])elvis,  coming  on  from  time  to  time  without  provocation,  and  accom- 
panied or  followed  by  a  purulent  discharge  from  the  uterus.  During 
the  attack  the  \)uUii  becomes  depressed  and  feeble,  the  surface  is  cov- 
ered by  a  cool  perspiration,  and  the  pain  is  often  so  severe  that  nothing 
short  of  hypodermic  doses  of  mor})hia  will  afford  relief. 

Exploration  of  the  pelvic  organs  will  in  many  cases  reveal  no  tumor; 
no  evidences  of  inflammatory  exudation  may  be  appreciable,  but  there 
will  be  tenderness  over  the  pelvic  roof.  The  patient  suffering  thus 
gives  the  history  of  jirolonged  invalidism,  of  fevers,  emaciation,  alxlom- 
iual  tenderness,  w  ith  meteorism,  painful  and  otherwise  disordered  men- 
struation. The  symptom  most  characteristic  of  these  cases  is  a  history 
of  repeated  attacks  of  pelvic  inflammatiou  without  appreciable  cause. 

Colica  seortorum,  though  generally  due  to  a  gonorrhoeal  endometritis, 
is  not  always  so.  It  signifies  occlusion  and  distension  of  a  Fallopian 
tube — pyosalpinx — the  uterine  mouth  of  the  tube  being  still  open.  The 
attacks  of  pain  are  due  to  contractions  of  the  muscular  walls  of  the  tube 
in  the  endeavor  to  expel  their  contents  through  a  small  orifice  into  the 
uterus. 

This  is  Lawson  Tait's  ^  explanation  of  the  symptom,  and  it  accords 
with  my  own  observations.  I  have  observed  this  svmptom  in  several 
cases  M-here  there  could  be  no  doubt  as  to  its  true  meaning  or  as  to  the 
diagnosis,  and  yet  a  physical  exploration  of  the  pelvis  would  throw  very 
little  if  any  light  upon  the  subject.  The  tubes  could  not  be  felt,  nor 
would  there  be  any  trace  of  tumor. 

Referring  to  this  subject,  Fritsch  ^  remarks :  "  It  is  noteworthy  that 
there  are  cases  of  this  nature  in  which,  despite  agonizing  suffering  for 
years,  neither  distinct  adhesions  nor  tumor  appear." 

Dr.  Thomas  Savage,^  speaking  of  disease  of  the  tubes,  states :  "  In 
some  instances  I  feel  sure  there  is  nothing  to  be  felt  in  the  pelvis  before 
operation,  and  we  have  nothing  to  guide  us  but  the  more  or  less  con- 
stant pain  and  recvu-ring  attacks  of  inflammation." 

Prognosis. — Simple  adhesive  pelvic  peritonitis  usually  runs  a  mild 
course,  and  complete  recovery  ensues.     The  uterus  is  often  displaced 

*  "  A  Clinical  Lecture."  X  Y.  Med.  Journ.,  Oct.  1?,  1884.  *  Op.  eit.,  p.  285. 

'  "  Diseases  of  the  Fallopian  Tubes."  18S3,  reprint  from  Birmingham  Med.  Bev. 


702  PERIUTEPdNE  INFLAMMATION. 

and  fixed  beyond  remedy  by  adhesions  to  the  rectum,  to  coils  of  intes- 
tine^ and  occasionally  to  the  bladder. 

Septic  peritonitis  is  attended  with  a  very  grave  prognosis  as  to  life. 
Peritonitis  of  gonorrhoeal  origin  usually  implies  sterility  and  invalid- 
ism for  years.  Purulent  peritonitis  is  a  much  more  serious  form  than 
the  sero-adhesive  variety.  The  puerperal  state  adds  much  to  the  grav- 
ity of  the  case.  In  attacks  of  even  moderate  severity-  the  prognosis 
should  be  guarded. 

In  view  of  the  frequency  of  collections  of  pus  in  the  tubes,  grave 
accidents  are  liable  to  happen  in  any  case. 

A  high  pulse  and  temperature  indicate  a  severe  attack,  but,  as  before 
shown,  a  low  temperature  does  not  necessarily  imply  a  favorable  prog- 
nosis. A^underlich  says :  "  Hyperpyretic  temperatm-es  in  peritonitis 
lead  us  to  suspect  an  infectious  origin,  and  indicate  a  speedy  death  with 
a  high  temperature." 

The  extension  of  the  disease  beyond  the  limits  of  the  pelvis  adds 
greatly  to  the  danger.     It  may  then  be  regarded  as  general  peritonitis. 

Although  this  form  of  pelvic  inflammation  often  entails  many 
untoward  results,  such  as  atrophy  of  the  ovaries,  obliteration  of  the 
tubes,  and  fixation  of  the  uterus  in  a  false  position,  and,  in  consequence 
of  these,  disorders  of  menstruation  and  sterilit}^,  yet  it  is  not  uncommon 
after  the  severest  attacks,  in  which  life  for  a  time  hangs  by  a  thread,  to 
see  recovery  complete  and  all  the  sexual  functions  re-established.  Men- 
struation again  goes  on  normally,  adhesions  undergo  aljsorption,  the 
-^vomb  recovers  its  proper  position,  and  conception  occurs. 

Treatmext. — The  most  important  principle  involved  in  the  treat- 
ment of  acute  pelvic  peritonitis  is  the  maintenance  of  absolute  physical 
rest.  Every  movement  of  the  body  should  be  prevented  as  far  as  pos- 
sible, and  the  patient  should  not  be  allowed  to  rise  or  to  leave  the  bed 
for  any  purpose  whatever  until  convalescence  is  established.  In  order 
to  put  this  principle  in  practice  opium  in  some  form  must  be  freely 
administered,  and  it  must  be  continued  to  the  verge  of  moderate 
narcotism  until  the  acute  stage  of  the  inflammation  has  subsided. 
After  this  the  doses  should  be  diminished  to  the  point  of  keeping  the 
patient  quiet  and  free  from  pain. 

In  severe  attacks  the  hypodermic  use  of  morphia  will  be  required  to 
bring  the  patient  under  the  influence  of  the  drug,  and  for  a  time  this 
method  of  continuing  its  use  will  be  necessary.  As  soon  as  possible, 
however,  it  is  better  to  substitute  for  it  the  administration  of  opium 
by  the  stomach. 

At  first  no  effort  should  be  made  to  move  the  bowels,  but  after  several 
days  have  elapsed  calomel  may  be  given,  in  one-grain  doses  every  three 
hours  until  three  or  four  grains  have  been  taken.  Tlien,  with  the  aid 
of  an  enema,  a  very  gentle  purgation  will  be  the  result,  the  gastric 


PELVIC  I'h'nrroyfTrs.  7();i 

symptoms  will  Ik-  lessened,  and  tlic  l)a([  <-llt'<'ts  of  opimn  upon  tlic 
secretions  will   l>e  diminislied. 

\\  liilc  |iiii<;ative  medicines  must  he  n-ed  wilii  extreme  <^ution,  or 
not  at  ail,  in  peritonitis,  wo  must  by  such  j^entle  measures  as  these 
throntrhout  the  diseitse  take  ("arc  that  fecal  uccunudations  do  not  w-cur. 

In  ilie  very  he<^inning  the  ai)pli("ation  to  the  abdomen  of  hot  turpen- 
tine stupas  or  hot  poultices  aifords  much  relief  to  the  pain.  Heat 
applied  to  the  extremities  will  also  be  required  in  the  state  of  dejues- 
sion  which  often  characterizes  the  early  stages  of  peritonitis.  Among 
the  remetlies  which  experience  has  shown  to  i)e  of  great  value  is  a, 
blister,  which  should  be  placed  over  the  hypogjistrium.  In  con- 
junction with  this  a  poultice  of  cooked  starch  should  i)e  made  to  cover 
the  entire  abdomen.  When  the  blistered  surface  has  healed  the  blister 
mav  from  time  to  time  be  reapplied  with  great  advantage;  and  as  long 
a-s  the  products  of  inflammatiou  are  appreciable,  warm  moist  dressings, 
in  some  form  or  other,  should  be  w^orn  ov^er  the  abdomen. 

If  the  temperature  runs  high,  reaching  104°  or  105°,  instead  of  the 
measures  just  mentioned  the  rubber  coil  or  some  other  device  for  the 
continuous  application  of  cold  to  the  abdomen  should  be  used.  Anti- 
pyrine  also,  either  by  stomach  or  enema,  is  of  the  greatest  value  in  the 
reduction  of  temperatm*e. 

Throughout  the  acute  stages  of  the  disease  the  diet  should  be  milk 
and  lime-water,  pancreatized  milk,  buttermilk,  and  animal  teas.  But- 
termilk is  nearly  a  perfect  diet,  theoretically  and  practically,  for  fever 
patients. 

Chronic  cases  are  to  be  treated  by  a  repetition  of  blisters,  the  external 
use  of  iodine,  and  the  wet  compress.  At  the  same  time,  the  utmost 
attention  should  be  paid  to  the  improvement  of  the  general  health  bv 
sunlight,  by  the  introduction  of  food  and  tonics  into  the  svstem,  and 
in  some  cases  by  passive  exercise  in  the  open  air  and  by  a  change  of 
climate. 

In  many  of  the  chronic  cases  M-e  shall  find  displacement  of  the  uterus 
backward,  tenderness  and  fulness  and  resistance  upon  pressure  in  the 
region  of  the  tubes,  and  one  or  both  ovaries  enlarged,  displaced,  and 
very  sensitive  to  the  touch.     Uterine  mobilitA'  is  also  impaired. 

One  very  important  principle  in  the  treatment  of  such  cases  is  rest. 
With  this  should  be  combined  sunlight  and  good  diet.  The  strictest 
attention  should  be  paid  to  the  improvement  of  the  digestion  and  to  the 
avoidance  or  relief  of  constipation.  Iron,  cod-liver  oil,  malt,  and  the 
hypophosphites  are  the  medicines  usually  found  most  beneficial  in  such 
cases. 

Much  may  be  accomjilished  for  the  relief  of  the  inflammation  by 
local  treatment  also.  The  Preissnitz  compress,  or  wet  bandages  covered 
with  rubber  cloth,  may  be  worn  around  the  hips  continuously,  night  and 


704  PEBIUTEEINE  INFLAMMATION. 

day,  until  the  skin  becomes  tender  and  irritated.  The  hot  vaginal 
douche,  used  in  large  quantities  twice  a  day,  at  a  temperature  115°  to 
120°  F.,  while  the  patient  is  in  the  recumbent  position,  is  an  agent  of 
great  value,  for  the  knowledge  of  which  the  profession  is  indebted  to 
Emmet. 

The  application  of  the  strong  tincture  of  iodine  to  the  vaginal  roof, 
a,nd  the  filling  of  the  upper  part  of  the  vagina  with  absorbent  cotton 
which  has  previously  been  saturated  with  pure  glycerin,  will  do  much 
toward  emptying  congested  tissues,  relieving  pain  and  soreness,  and 
promoting  absorption  of  the  exudation. 

Cautious,  gentle  efforts  by  manual  or  other  pressure  should  be  made 
to  restore  the  uterus  to  its  proper  position  if  it  has  been  displaced.  But 
the  use  of  the  sound  or  the  probe  or  the  repositor  for  this  purpose  will 
be  attended  with  very  great  danger  of  provoking  a  fresh  endometritis, 
a  salpingitis,  and  a  peritonitis.  If  the  retroversion  can  be  corrected,  a 
pessary  may  be  watchfully  used  to  keep  the  uterus  in  place,  provided 
the  tenderness  has  been  previously  removed  by  the  means  just  described. 

In  some  cases,  after  the  peritonitis  has  disappeared  a  most  troublesome 
feature  will  remain  and  baffle  the  most  patient  and  persevering  treat- 
ment. One  of  the  appendages,  the  ovary  or  the  tube,  will  remain 
displaced,  tender,  adherent  in  Douglas's  pouch  or  in  one  of  the  retro- 
uterine shelves,  and  we  cannot  dislodge  it.  The  patient  will  suffer 
much  from  this  alone.  She  will  experience  nearly  constant  pain,  inabil- 
ity to  stand  or  exercise — will  be  nervous  and  suifer  from  backache  and 
from  irritable  bladder. 

After  the  appendages  have  been  fixed  by  adhesions  in  the  manner 
and  position  here  described,  I  know  of  no  means  which  we  possess  for 
dislodging  them  save  by,  removal  through  abdominal  section. 

While  much  of  good  can,  as  a  rule,  be  accomplished  by  the  plan  of 
treatment  just  described,  cases  are  frequently  met  with  in  which  no 
improvement  whatever  follows.  Kepeated  attacks  of  inflammation 
arise  from  time  to  time,  exhausting  the  patient's  strength,  or  else,  at 
some  period  in  the  history  of  a  case  which  perhaps  has  been  chronic 
from  the  beginning,  violent,  acute  symptoms  are  developed,  indicating 
general  peritonitis. 

The  proper  treatment  for  such  cases  is  now  generally  admitted  to  be 
that  which  has  been  made  clear  by  Mr.  Lawson  Tait.  His  method 
consists  in  opening  the  abdomen  by  an  incision  between  the  umbilicus 
and  pubes,  removing  the  diseased  ovaries  and  tubes  which  tend  to  per- 
petuate the  inflammation,  evacuating  accumulations  of  serum  and  pus, 
carefully  cleansing  the  peritoneum,  and  in  proper  cases  making  use  of 
drainage.  This  method  is  a  rational  deduction  from  the  pathology  of 
pelvic  peritonitis  as  it  was  given  to  us  by  Bernutz.  It  is  also  the  appli- 
cation of  a  surgical  principle  which  has  afforded  the  best  results  in  the 


PELVIC  ('KLIA'IJTIS.  705 

treatiuciit  of  pniiilriii  iiitl;iiiiiii:iti(iiis  in  otlwi-  cavities  of  the  \un\\-  liiictl 
bv  serous  iiR'iiil)iaiu's. 

This  surgeon,  wlio  has  ublaineil  sudi  brilliant  results  I'roin  abdominal 
section,  says:  "  By  no  means  the  least  satisfactory  groups  in  the  above 
list  are  those  of  acute  and  chronic  i)eritonitis.  In  these  c<Lses  absolute 
cures  have  been  etiected,  in  every  instance  by  the  simple  ])lan  of  open- 
ing the  peritoneal  cavity,  cleaning  it  out,  and  draining  it  for  a  short 
time.  That  tluy  were  cases  of  an  extreme  kind  might  be  shown  by 
their  details,  but  probably  one  will  suffice.  I  take  the  following  descrip- 
tion of  the  patient's  condition  from  a  letter  written  to  me  by  Dr.  Justin 
McCarthy,  who  sent  her  to  me :  '  The  condition  in  which  I  found  her 
was  one  of  the  greatest  emaciation  :  seldom  have  I  seen  it  greater,  unless 
in  the  last  stage  of  phthisis.  There  was  an  enlargement  of  the  abdomen 
of  rapid  growth,  and  she  had  incessant  vomiting  and  diarrlujia,' " 

In  addition  to  these,  Mr.  Tait  published  in  the  Briti-ih  Med.  Journ., 
June  28,  1884,  5  cases  of  extra-uterine  pregnancy  operated  on  by 
abdominal  section  shortly  after  rupture  of  the  tube.  In  these  cases 
he  was  practically  cidled  upon  to  deal  with  a  severe  peritonitis,  since 
the  condition  was  marked  by  rapid  pulse  and  high  temperature.  Four 
of  these  ca.ses  were  thus  successfully  treated.  Very  soon  after  he  pub- 
lishetl  his  results  in  18  other  cases,  making  23  in  all,  with  but  a  single 
death. 

The  cases  to  which  treatment  by  abdominal  section  is  applicable  may 
be  classified  under  the  following  heads : 

1.  Those  chronic  cases  in  which  the  sufferer  has  made  full  use  of  the 
treatment  discussed  in  this  article  without  benefit,  and  has  become  a 
helpless  invalid. 

2.  Those  cases  in  which  the  condition  resembles  the  last  stage  of 
phthisis,  and  the  presence  of  pus  is  indicated  by  the  symptoms  of 
hectic. 

3.  Chronic  cases  in  which  the  symptoms  have  become  suddenly  and 
urgently  acute,  and  there  are  good  grounds  for  the  conclusion  that  ru[)- 
ture  of  a  pyosalpinx  or  an  ovarian  abscess  has  occurred. 

4.  Acute  cases  in  which  the  pulse  and  temperature  run  high,  and  the 
history  justifies  the  presumption  that  the  peritonitis  is  due  to  rupture  of 
the  tube  from  a  Fallopian  pregnancy. 

To-day  there  is  nothing  l)etter  established  in  surgery  than  the  treat- 
ment, in  jjroper  cases,  of  peritonitis  by  abdominal  section  and  drainage. 

Pelvic  Cellulitis. 

SvNOXYMS. — 1.  Periuterine  phlegmon  (XonatV,  2.  Parametritis 
(Yirchow,  ^Matthews  Duncan,  Schroeder) ;  3.  Periuterine  cellulitis 
(Thomas). 

Vol.  L — io 


706  PERIUTERINE  INFLAMMATION. 

The  term  "  pelvic  cellulitis  "  is  here  applied  to  an  inflammation  of 
Virchovv's  parametric  tissue,  which  surrounds  the  cervix  and  upper 
portion  of  the  vagina ;  and  of  the  connective  tissue  which  extends  from 
the  sides  of  the  uterus  between  the  layers  of  the  broad  ligaments.  Orig- 
inating thus,  the  inflammation  may  extend  to  the  connective  tissue  in 
other  parts  of  the  pelvis. 

Etiology. — Inflammation  of  tlie  cellular  tissue  in  any  part  •  of  the 
body  may  arise  from  traumatism  applied  directly  to  the  tissue  itself; 
or  from  extension  of  inflammation  from  some  adjacent  organ ;  or  else 
from  septic  material  introduced  at  a  remote  point  and  conveyed  to  it 
by  bacteria  through  the  lymphatic  and  blood-vessels. 

Pelvic  cellulitis,  pure  and  simple,  is  a  rare  disease.  It  is  most  com- 
monly met  with  after  parturition,  and  is  associated  with  an  evident 
septicemia.  The  inflammation  is  not  confined  to  the  cellular  tissue, 
but  usually  involves  also  the  endometrium,  the  membrane  lining  the 
tubes,  and  the  pelvic  peritoneum. 

In  this,  the  puerperal  form,  the  cellulitis  has  its  origin  in  a  septic 
infection,  the  poison  being  introduced  from  without,  and  gains  admis- 
sion to  the  system  through  some  one  of  the  numerous  abrasions  to  which 
the  genital  passages  are  liable  in  parturition.  Its  occurrence  is  inti- 
mately connected  with  the  presence  of  bacteria ;  and  it  is  now  quite 
generally  conceded  that  for  the  production  of  the  cellulitis  there  must 
be  bacteria,  which  are  introduced  from  without.  There  must  also  be 
solution  of  continuity  in  the  tissues  of  the  vagina  or  the  cervix,  through 
which  the  bacteria  gain  entrance  to  the  blood. 

Striking  proof  of  the  truth  of  this  view  is  furnished  by  the  experi- 
ence of  the  New  York  Maternity  Hospital.  Since  the  adoption  of 
Garrigues's  method  of  prophylaxis,^  the  percentage  of  sepsis  has  been 
reduced  to  .21 ;  before  its  adoption  the  percentage  of  sepsis  was  6.06. 
The  introduction  of  the  same  method  into  the  Boston  Lying-in  Hos- 
pital^ has  reduced  the  percentage  of  sepsis  to  .0. 

Steurer's  microscopic  investigations  of  the  Strasbourg  epidemic,  under 
the  guidance  of  Yon  Recklinghausen,  showed  that  from  the  diphtheritic 
patches  on  the  vulva  and  the  vaginal  and  uterine  mucous  membrane 
"  bacteria  could  be  traced  between  the  muscular  fibres  and  deep  down 
into  the  canalicular  spaces  of  the  connective  tissue,  where  their  pres- 
ence gave  rise  to  cellulitis."^ 

In  the  non- puerperal  woman  pelvic  cellulitis  is  chiefly  observed  in 
connection  with  surgical  operations  upon  the  cervix  uteri,  and  is  here 

^  Antiseptic  Midwifery,  by  Dr.  H.  J.  Garrigues,  1886. 

^  "Antiseptics  in  Obstetric  Practice,"  by  W.  L.  Eichardson,  M.  D.,  Boston  Med.  and 
Surg.  Journ.,  Jan.  27,  j  887. 

'^Science  and  Art  of  Midivifery,  by  W.  T.  Lusk,  A.  M.,  M.  D.,  1882,  p.  617. 


PKLVIC  Ci:  LLC  LITIS.  707 

also  of  a  s(>|)ti<'  cliai'actcr.  It  is  not  a  simple  cellulitis,  \n\{  is  associated 
willi  peritonitis,  as  in  the  puerpei'al  siiWjecls. 

Tlie  old  method  of  treating'  uterine  poly|)us  li\-  deliiiation  was  not 
iinl'ri'(|nenilv  lollowed  hy  a  >epiie  intlammalion,  which  nj)on  aiitopsv 
was  t'oiind  to  l)e  pelvic  ct'llidiiis  with  al)Uiidunt  evidences  (if  perito- 
nitis.' 

Dilatation  of  the  uterus  hy  tents,  particidarly  s))on<i:('  t<.'nts,  has  so 
often  lu'cn  followed  by  severe  and  even  fatal  celliditis  that  the  physi- 
cian who  uses  them  except  for  good  reasons  and  after  surroiuiding 
his  patient  hy  all  known  safeguards,  lays  himself  justly  o})en  to 
censiuv. 

While,  then,  such  is  commonly  the  etiology  of  ])elvie  eellulitis,  to 
use  the  words  of  Fritseh,'  "  it  woidd  be  sacrificing  truth  to  a  principle 
were  we  to  assert  that  every  parametritis  is  a  traumatic  aliection  based 
on  infection."  For  in  young  girls  and  old  women  pelvic  cellulitis 
sometimes  occurs  without  any  recognizable  lesion,  and  now  and  then 
oin-  attention  is  called  to  it  in  women  in  whom  no  uterine  disease  has 
previously  been  suspected. 

Circumscribed  inflammations  of  the  cellular  tissue,  non-septic  in 
character,  probably  arise  froiu  injury  of  the  tissues  of  the  cervical 
canal,  the  process  being  propagated  by  continuity  through  the  inter- 
muscular connective  tissue  to  the  connective  tissue  on  the  sides  of 
the  uterus  or  to  that  between  the  peritoneal  folds  constituting  the 
utero-sacral  ligaments.  This  is  Bandl's  explanation  of  utero-sacral 
celliditis. 

Emmet  ^  has  met  with  two  cases  of  cellulitis  in  children  between 
eight  and  ten  years  of  age,  and  the  records  of  his  private  hospital 
contain  the  liistories  of  15  cases  of  cellulitis  after  the  menopause. 

When  we  consider  the  change  which  our  views  have  undergone 
within  the  last  few  years  in  regard  to  the  differentiation  of  pelvic 
exudations,  some  doubt  might  naturally  arise,  in  the  absence  of  autop- 
sies, concerning  the  true  nature  of  these  cases.  But  Aran  *  reported  the 
case  of  a  woman  eighty  years  of  age  whom  he  examined,  and  in  whom 
he  found  a  swelling  on  the  side  of  the  uterus  encroaching  on  the  lateral 
Avail  of  the  vagina,  which  after  death  was  found  to  consist  of  indurated 
cellular  tissue,  presenting,  under  examination  by  Ch.  Robin,  numerous 
fibro-plastic  cells. 

In  some  cases  the  cellulitis  is  due  to  a  htematoma.  In  these  the  effu- 
sion of  blood  takes  place  between  the  layers  of  one  broad  ligament  by 
rupture  of  its  vessels  or  from  the  veins  of  the  parametric  tissue. 

Pelvic  cellulitis  is  essentially  an  acute  disease.    If  at  times  it  appears 

^  Diseases  of  WortuTt,  by  Alfred  II.  MoC'lintock. 

^  Di-^onses  of  Women,  by  Heinrich  Fritseh. 

^  Op.  cil..  p.  249.  *  Legons  dinique^,  p.  657. 


708  PERIUTERINE  INFLAMMATION. 

to  be  chronic,  it  is  so  because  of  its  association  with  pelvic  peritonitis, 
to  the  continuance  of  which  it  owes  its  chronicity. 

Professor  Freuncl  of  Strassburg  has  described  a  chronic  inflammation 
of  the  pelvic  connective  tissue  which  has  no  acute  stage.  To  this  he 
gave  the  name  parametritis  chronica  atrophicans  circumscripta  et  dif- 
fusa. An  account  of  his  investigations  has  been  presented  to  the 
English  reader  in  the  admirable  manual  of  Hart  and  Barbour/  and 
from  that  source  I  derive  my  information. 

The  etiology  of  this  form  of  cellulitis  circumscripta  is  to  be  found 
in  ulcerative  processes  in  the  bladder,  rectum,  and  uterus.  Ulcerations 
in  the  bladder  and  rectum  produce  inflammation  in  the  connective  tissue 
surrounding  those  organs.  Cicatricial  formations  with  atrophy  and  con- 
traction are  the  result,  and  the  uterus  is  made  to  deviate  from  its  nor- 
mal position.  Cicatricial  tissue  on  the  sides  of  the  bladder  gives  rise  to 
right  and  left  retroflexions  of  the  uterus. 

The  result  of  dysenteric  or  simple  follicular  ulcers  in  the  rectum  is 
cellulitis  in  the  utero-sacral  ligaments,  which  causes  pathological  ante- 
flexion. 

Laceration  of  the  cervix  is  assigned  as  a  cause  of  chronic  cellulitis 
at  the  base  of  the  broad  ligaments.  This  in  time  produces  lateral 
displacement  of  the  uterus,  compression  of  veins  and  nerve-filaments, 
with  cervical  catarrh  and  reflex  pains. 

Pathology. — This  form  of  pelvic  inflammation  is  of  very  frequent 
occurrence.  Hart  and  Barbour  remark  :  "  Thus,  split  cervix,  so  com- 
mon in  women  who  have  borne  children,  is  almost  always  associated 
with  some  cellulitis  at  the  base  of  the  broad  ligaments." 

The  first  result  of  inflammation  of  the  cellular  tissue  is  a  sero-fibrin- 
ous  exudation  from  the  blood-vessels.  The  tissue  is  then  infiltrated  by 
young  cells  which  arise  from  proliferation  of  the  connective-tissue  cor- 
puscles. Their  ranks  are  rapidly  swollen  by  the  emigration  of  white 
blood-corpuscles  from  the  capillaries. 

As  a  result  of  pressure  from  this  exudation  and  the  crowding  of 
young  cells,  complete  stasis  of  blood  occurs  in  the  capillaries ;  necrosis 
of  the  intercellular  substance  takes  place;  liquefaction  follows,  and 
suppuration  is  the  result. 

If  the  inflammatory  process  stops  short  of  the  formation  of  pus, 
resolution  occurs,  and  the  result  is  the  production  of  a  fibrous  material 
whose  characteristic  property  is  contractility.     This  is  cicatricial  tissue. 

Cicatricial  tissue  in  one  of  the  broad  ligaments  causes  a  lateral  ver- 
sion of  the  uterus ;  in  the  utero-sacral  ligaments,  traction  upward  and 
backward  of  the  cervix,  which  gives  rise  to  pathological  anteflexion 
with  its  consequences,  dysmenorrhoea  and  sterility. 

Some  writers  allege  that  cellulitis  never  exists  alone,  but  is  alwavs 

^  Manual  of  Gyncecology,  3d  ed.,  Edinburgh,  1886. 


PELVIC  ci:LLri.n'is.  7<)i» 

ass()ci:it('<l  with  iiiDfc  ur  Ic-s  |)cl\ic  |icrit<»iiili-.  riitif  is  siitliriciil  (-vi- 
(Iciicc  to  sIkjnv  that  this  npinidn  is  incorrect. 

('oiirtv'  (U'clafcs  tiiat  hi-  lias  seen  a  |>iil('<i;iii<>ii  ol'  the  rijilit  hroad 
li^-aiiKMit  open  into  the  roctuiu,  and  one  of  the  left  li<raineiit  into  tlie 
va«^ina,  without  <2:ivin<>;  rise  to  any  symptoms  of  jxiritonitis;  also,  eases 
of  ehroni(^  cellulitis  j^ivin<^  rise  to  cicatricial  bands,  with  displacement 
of  the  uterus,  without  a  sym})tom  of  peritonitis  durinj^;  life,  and  leavinj^ 
no  trace  whii'h  could  he  discovered  at  death.  He  quotes  Frarier's  rase 
of  suj)puratiu<!:  phlet!:inou  of  the  ri<rlit  broad  lij^ament  openinjr  into  the 
bla(l(h'r,  the  autojjsy  proviuo;  that  the  })eritoneum  did  not  participate  in 
the  inllainniation.  In  Behier's  case  a  suppurating;  })hlegmon  <jf  the  left 
l)road  iiuainciit  extended  to  the  iliac  foasa  after  delivery,  and  terminated 
fatally.  There  was  no  alteration  of  the  })eritoneuni.  Courty  adds  that 
an  equally  conclusive  case  has  come  under  his  own  observation.  The 
same  author  quotes  the  publisiied  cases  of  Simon  and  Alph.  Guerin  as 
coni'lusive  examples  of  ante-uterine  and  retro-uterine  cellulitis  without 
organic  alteration  of  the  serous  membrane. 

I  have  myself  carefully  observed  in  a  non-puerperal  woman  an 
extensive  exudation  going  on  to  suppuration  in  the  cellular  tissue  of 
the  left  broad  ligament  and  side  of  the  pelvis.  During  the  entire  his- 
tory of  the  case  there  was  absence  of  pain  and  tenderness  in  the  exu- 
dation. After  death,  from  double  i^ueumouia,  there  were  no  signs  of 
peritonitis. 

These  cases  must  be  considered  as  exceptional.  Usually,  autopsies 
show^  all  the  pelvic  viscera  matted  together  by  exudation,  the  cellular 
tissue  infiltrated  with  pits,  the  uterus,  ovaries,  and  intestines  adhering 
by  fibrinous  bands,  and  the  Fallopian  tubes  dilated  by  serum  and  pus. 

Pelvic  cellulitis  may  be  general  or  localized.  "When  general,  it  begins 
in  the  parametric  tissue,  extends  thence  to  the  broad  ligament,  involving 
all  the  connective  tissue  between  its  folds.  It  then  travels  to  the  side 
of  the  pelvis,  perhaps  going  into  the  iliac  fossa,  or  along  the  side  of  the 
bladder  to  the  retro-pubic  cellular  tissue  and  that  of  the  anterior  abdom- 
inal wall.  The  most  common  seat  of  pelvic  cellulitis  is  the  connective 
tissue  of  one  of  the  broad  ligaments.  It  is  seldom  that  both  broad 
ligaments  are  involved  at  the  same  time. 

As  death  is  exceedingly  rare  in  cases  of  simple  circumscribed  ]ielvic 
cellulitis,  we  have  to  rely  for  the  proof  of  its  existence  on  clinical  evi- 
dence almost  entirely.  Fortunately,  this  evidence  may  be  very  satis- 
factory, because  of  the  ease  with  which  the  tissue  around  the  cervix  can 
be  reached  by  the  examining  finger.  This  is  especially  true  in  regard 
to  the  small  swellings  in  front  of  and  behind  the  cervix.  The  swellings 
which  are  formed  on  the  sides  of  the  uterus  have  long  been  the  subject 
of  dispute,  and   involve    much    more  difficulty  in    diagnosis.     Xonat 

'  Op.  cit.,  p.  532. 


710  PERIUTERINE  INFLAMMATION. 

claimed  that  they  were  all  due  to  phlegmons  of  the  parametric  tissue. 
Bernutz,  ou  the  other  hand,  showed  by  his  autopsies  that  they  are  often 
the  result  of  pelvic  peritonitis. 

Dr.  Thomas/  who  has  examined  the  post-mortem  reports  of  a  large 
number  of  authorities,  states  "  that,  so  far  as  his  knowledge  extends, 
there  are  only  two  cases  of  such  limited  cellulitis  substantiated  by 
autopsic  evidence — one  reported  by  Demarquay,  the  other  by  Simon." 
He  considers  that  "  one  of  these,  that  of  Simon,  is  conclusive  of  the 
possibility  of  such  disease ;  that  of  Demarquay  is  doubtful,  for  with 
the  abscess  in  the  cellular  tissue  there  was  also  one  in  the  cul-de-sac 
of  Douglas." 

In  addition  to  this  unquestioned  case  of  Simon's,  Courty,^  quotes  a 
similar  one  by  Alphonse  Guerin  resulting  from  direct  traumatism  in 
the  ablation  of  a  polypus  situated  in  the  anterior  wall  of  the  cervix. 
He  also  refers  to  an  important  autopsy  by  Naudier,^  which  is  quoted 
here  as  not  only  conclusive  of  the  possibility  of  such  disease  as  we  are 
considering,  but  as  demonstrating  the  occasional  existence  of  large  retro- 
uterine cellulitic  abscesses. 

Naudier's  patient  suffered  from  hypertrophic  elongation  of  the  neck. 
"  The  abscess  which  was  evacuated  through  the  anterior  wall  of  the 
rectum  extended  behind  the  whole  of  the  vagina,  the  whole  posterior 
surface  of  the  uterus,  and  laterally  to  the  inferior  border  of  the  left 
ovary ;  pelvic  peritonitis  had  only  slowly  followed  the  formation  and 
evacuation  of  this  abscess ;  the  annexes  of  the  uterus  and  the  parts  sur- 
rounding Douglas's  space  could  not  be  considered  as  the  starting-point 
of  this  retro-uterine  cellulitis :  the  case  proves  these  two  points." 

Lymphangitis  and  phlebitis  are  generally  found  coexisting  with  cel- 
lulitis. We  must  regard  the  lymphangitis  merely  as  the  result  of  the 
operation  of  the  poison,  which  while  travelling  along  the  lymphatics  has 
caused  the  cellulitis.  Phlebitis  in  the  puerperal  woman.  Trousseau 
taught,  is  the  result  of  an  extension  of  inflammation  from  the  uterine 
sinuses  along  the  Avails  of  the  veins.  In  the  non-puerperal  cases  it  is 
probably  at  first  a  periphlebitis  due  to  extension  of  the  cellular  inflam- 
mation to  the  sheath  primarily,  and  later  to  the  inner  coat  of  the  vein. 

Routes  along  Schick  Pus  Travels. — It  is  important  to  observe  the 
routes  along  which  pus  travels  in  the  pelvic  cellular  tissue. 

In  puerperal  cases,  when  pus  forms  in  the  iliac  fossa  it  usually 
works  forward  and  points  above  Poupart's  ligament.  Very  rarely  it 
behaves  like  a  psoas  abscess,  and,  making  its  way  beneath  Poupart's 
ligament,  forms  a  tumor  on  the  inner  aspect  of  the  thigh.  Puerperal 
abscesses  not  unfrequently  travel  downward  alongside  the  vagina  and 
open  in  the  labium,  or  at  some  other  point  near  the  ostium  vaginae,  or 

1  Op.  ciL,  p.  478,  5th  ed.  '  Op.  ciL,  p.  533. 

^  Annates  de  Gynecologic,  vi.  293. 


i'i:i.vi<'  CFLLr LITIS.  7;  1 

tlii"iMit;li  the  intc-iuiiiriit  near  the  anus.  In  dtlicr  cases  still  llic  |ins 
makes  a  way  tlii'niij^h  the  sciatif  loranicn,  and  upcns  lliion^ii  llic  t:lnt<i 
iinisclcs  nr  tiirntiuli  the  ohturator  loruiiicn. 

Vvvv  tVccjUcntiy  these  abscesses  open  into  the  \a;^ina,  the  iiieni-.,  the 
hladtler,  or  the  rectum.  The  iioii-jjiierperal  cases  nearly  alwavs  open 
into  one  ol"  these  viscera.  It  is  rare  tor  them  to  open  into  the  perito- 
neum, thoiii^h  Di".  McCIintoek '  siiys :  "It  is  very  rcmarkahle  that 
while  three  of  the  seven  non-])iierperal  cases  of"  ahscess  were  broiiirht 
to  a  sucKK'ii  and  ahriipt  termination  by  burstin<r  of  the  sac  into  the 
peritoneal  cavity,  no  such  accident  ever  occurred  in  all  my  experience 
of  pelvic  abscess  succeedinjj;  to  parturition." 

Usually,  the  direction  in  which  the  intiammatory  process  travels  will 
depend  on  the  route  taken  by  the  lymphatic  vessels.  But,  a.s  Lusk 
remarks,  it  also  "follows  j)rearranged  pathways  in  the  connective 
tissue."  This  has  been  shown  by  the  experiments  of  Konig  and 
Schlesinger,  who  injected  air,  water,  and  liquefied  glue  at  various 
points  in  the  pelvic  connective  tissue,  and  then  studied  the  direction 
taken  by  these  substauces. 

Symptoms. — Pelvic  cellulitis  in  the  puerperal  woman  may  be  cir- 
cumscribed, or  limited  to  the  parametric  tissue  on  the  sides  of  the  uterus, 
and  may  not  extend  beyond  the  nearest  lymphatic  glands.  This,  how- 
ever, is  veiy  rare,  for  in  most  cases  the  inflammation  spreads  from  the 
intermuscular  connective  tissue  of  the  uterus  along  the  lymphatics, 
causing  a  lymphangitis,  and  involves  the  connective  tissue  of  the  broad 
ligament,  and  often  that  of  the  iliac  fossa  also. 

Under  these  circumstances  the  adjacent  peritoneum  is  usually  inflamed 
also,  so  that,  practically,  Ave  can  seldom  differentiate  cellulitis  from  ])eri- 
tonitis.  Hence  puerperal  pelvic  cellulitis  can  scarcely  be  considered 
separately  from  pelvic  peritonitis. 

In  the  account  of  symptoms  here  given  I  have  followed  Dr.  Lusk,- 
who  borrows  from  Olshausen. 

Hardly  ever  later  than  the  fourth  day  after  labor,  and  most  usually 
on  the  second  or  third,  the  patient  has  chilly  sensations  or  else  a  decided 
chill,  followed  by  rapid  rise  of  temperature.  On  the  second  and  third 
days  of  the  fever  the  thermometer  in  the  axilla  rises  higher  and  higher, 
so  that  there  is  often  registered  a  temperature  ranging  from  103°  to 
105°.  This  fever  then  gradually  subsides,  ending  in  about  70  per  cent, 
of  the  cases  in  seven  or  eight  days,  in  20  per  cent,  in  two  weeks,  and 
prolonged  beyond  that  period  in  only  10  per  cent,  of  the  cases.  If  the 
fever  continue  into  the  fifth  or  sixth  Aveek,  it  Avill  probably  be  due  to 
the  occurrence  of  suppuration.  Suppuration  may,  however,  occur  in 
severe  c^ses  within  a  week  from  the  beginning  of  the  attack. 

The  fever  does  not,  however,  always  pursue  the  coui-se  here  described. 
1  Op.  ciL,  p.  50.  2  Op.  cil. 


712  PEEIUTEEINE  INFLAMMATION. 

Sometimes,  after  a  few  clays,  the  temperature  will  be  normal  in  the 
morning,  but  elevated  in  the  evening,  so  as  to  lead  to  a  suspicion  of  its 
being  malarial  in  character.  Doubt  about  its  nature  can  usually  be  re- 
moved by  a  physical  exploration  of  the  pelvis,  which  in  case  of  inflam- 
mation will  reveal  an  area  of  tenderness  in  close  proximity  to  the  uterus. 

The  pulse  ranges  from  120  to  140  per  minute.  It  rarely  goes  above 
120  in  inflammations  of  moderate  extent.  Its  persistence  for  twenty- 
four  hours  in  the  neighborhood  of  140  is  indicative  of  septicaemia. 

In  many  cases  the  chill  is  accompanied  by  severe  lancinating  pain, 
coming  in  paroxysms  like  after-pains.  This  pain  is  due  to  the  accom- 
panying peritonitis.  In  the  rare  cases  of  pure  cellulitis  it  is  not  a 
noticeable  feature. 

Vomiting  is  not  present  to  any  marked  degree  unless  the  peritonitis 
becomes  general. 

In  portions  of  the  country  where  malarial  fevers  are  prevalent  I 
have  been  led  into  an  error  of  diagnosis  by  supposing  to  be  bilious 
remittent  what  was  really  simple  circumscribed  pelvic  cellulitis.  By 
way  of  illustration  :  A  woman  who  has  borne  several  children  falls  into 
labor,  and  after  two  or  three  hours  is  delivered.  Everything  passes  off 
in  the  easiest  manner  conceivable,  and  there  is  nothing  to  suggest  the 
slightest  injury  to  the  genital  canal.  On  the  third  or  fourth  day,  how- 
ever, there  is  a  slight  chill,  followed  by  fever,  which  rises  higher  and 
higher  on  the  second  and  third  days  of  the  attack,  and  declines  after- 
Avard,  under  a  treatment  by  quinine,  to  complete  defervescence  on  the 
fifth  day,  running  a  course  which  I  have  demonstrated  elsewhere  ^  to  be 
the  typical  course  of  bilious  remittent  fever,  and  which  is  almost  iden- 
tical with  that  of  simple  traumatic  fever,  whose  thermometric  range  has 
been  drawn  by  Billroth.^  During  such  an  attack  the  patient  repeatedly 
denies  the  existence  of  pain  in  the  pelvis.  There  is  no  decided  tender- 
ness on  pressure  over  the  abdomen,  and  no  evidence  of  inflammatory 
exudation  is  at  first  observable  on  vaginal  exploration.  Three  or  four 
days  after  tlie  subsidence  of  these  symptoms  it  is  perhaps  observed  that 
there  is  a  return  of  fever  in  the  evening,  which  declines  toward  morn- 
ing and  rises  again  in  the  evening,  and  is  of  decidedly  remittent  charac- 
ter. Matters  thus  progress  until  some  time  during  the  second  week 
after  delivery,  when  exudation  becomes  manifest  in  one  of  the  broad 
ligaments,  and  a  dull  pain  is  felt  in  the  same  region.  It  now  becomes 
clear  that  the  attack  was  inflammatory  in  character  from  the  beginning, 
and  examination  Avill  usually  reveal  a  laceration  of  the  cervix  on  the 
side  corresponding  to  the  exudation.  In  many  of  the  slight  attacks 
the  fever  subsides  on  the  fifth  day :  in  these  there  Avill  seldom  be  an 
appreciable  exudation. 

'  Amer.  Journ.  Med.  Sciences,  April,  1881. 

^  Surgical  Pathology,  4th  ed.,  p.  330,  translated  by  Hackley. 


I'KiMc  ci: LI. ('LITIS.  7i;; 

Tlic  ('\u<l:itiiiii  tiiiiKiris  ntimdrd  in  Innii,  \;iii:il)l('  in  size,  stidutii 
exci'ctliiii:,'  an  ;i|)|>lc  in  its  dimensions,  and  sitnatcd  iK'tuccn  the  lavcrsol' 
till'  Id-oad  liiiaiuent.  'I'lir  ntci'ns  is  soincwliat  fixed,  and  pushed  hy  the 
tnnmr  to  the  opposite  side  of  the  pel\i>.  In  .-onic  eases,  after  ilie  hipsu 
of  a  few  weeks,  the  oxiuhition  beeonies  ot"  ahuost  stony  har»hies~;,  and 
piTSLMits  as  nuieh  resistance  to  the  linger  us  would  an  exostosis  growing 
from    the   peKie    wail. 

Tlu'  exudation  need  not  he  limited  to  the  hi'oad  ligament,  hut  niav 
extend  to  the  j)elvi('  walls,  or  even  invade  the  iliac  f'o.ssa,  and  I'oi'm  a 
large  tumor  casilv  discerned  through  the  ahdoininal  waU.  In  I'cgard 
to  these  tumors  Lusk  '  remarks  that,  "  a.s  the  exudation  between  the 
broad  ligaments  may  have  been  slight  from  the  beginning,  or  may  have 
subsequently  disappeared  by  absorption,  the  iliac  tumors  have  often 
apparently  a  spontaneous  origin."  Sometimes  the  exudation  within  the 
])elvis  is  so  extensive  as  to  give  to  the  examining  hand  the  impression 
that  it  has  been  freely  poured,  as  it  were,  from  above  among  all  the 
viscera,  and  lias  solidified  into  one  solid  mass. 

Some  of  these  exudations  are  not  sensitive  at  all,  while  others  are 
very  painful  upon  the  slightest  pressure.  The  amount  of  discomfort 
occasioned  by  the  exudation  will  depend  much  on  its  situation.  Tn 
one  ease  the  functions  of  the  bladder  will  be  greatly  disturbed  by  the 
tumor;  in  another  the  rectum  \yill  suffer  most;  while  in  a  third,  the 
exudation  being  among  the  psoas  and  iliac  muscles,  extension  of  the 
thigh  will  be  painful. 

When  the  fever  subsides  the  exudation  begins  to  undergo  absorption, 
and  in  a  few  weeks  may  entirely  disappear.  In  other  cases  its  removal 
is  slow,  and  it  remains  as  an  indurated  mass  for  many  months. 

The  continuance  of  fever  for  five  or  six  weeks  generallv  means  the 
formation  of  pus.  The  occurrence  of  suppuration  is  marked  bv  acute 
pain  in  the  inflamed  part,  by  great  sensitiveness  of  the  exudation,  by 
chills  and  evening  fevers  of  high  grade,  and  by  night-sweats.  Very 
soon  fluctuation  will  be  detected  in  the  tumor,  and  the  precise  location 
of  the  pus  can  be  fixed  by  exploration  with  the  hyjiodermic  needle. 

According  to  Olshausen,  the  abscess,  if  left  to  itself,  will  generallv 
discharge  just  above  Poupart's  ligament ;  next  in  frequency  ruptiu-e 
takes  place  into  the  colon;  rarely  into  the  bladder,  uterus,  and  vagina, 
and  most  rarely  of  all  into  the  peritoneal  ctivity. 

If  we  attempt  a  description  of  the  clinical  features  of  non-pucrpcral 
])elvic  cellulitis,  we  shall  find  them  diflering  in  no  material  respect  from 
those  which  characterize  the  puerperal  form  of  the  disease.  Generally, 
the  symptoms  of  the  former  are  less  severe  and  the  exudation  confined 
by  more  moderate  limits.  It  must  not  be  forgotten,  however,  that  in 
acute  pelvic  cellulitis,  whether  puerperal  or  not,  pelvic  peritonitis  usually 

1  Op.  cit. 


714  PERIUTERINE  INFLAMMATION. 

exists  also.  In  such  eases  there  are  present  intraperitoneal  as  well  as 
extraperitoneal  exudations.  As  stated  by  Lusk,  "  In  suppuration  of 
parametritic  exudations  the  pus  commonly  forms  in  small  scattered 
collections,  and  rarely  gives  rise  to  large  abscesses." 

In  the  non-puerperal  form  metrorrhagia  is  one  of  the  earliest  symp- 
toms, yet,  according  to  my  observation,  it  is  not  peculiar  to  cellulitis, 
but  belongs  to  periuterine  inflammation  in  general. 

It  is  quite  common  to  observe  cases  in  which  there  is  no  chill  and 
little  fever,  but  considerable  pain.  And,  again,  there  is  a  class  of  cases 
which  give  no  history  of  any  febrile  movement  and  complain  of  no 
pain.  In  these  the  patient  is  j^ale,  weak,  and  somewhat  emaciated. 
There  is  failure  of  appetite  and  digestion,  with  a  sense  of  pelvic  uneasi- 
ness and  pressure,  and  a  derangement  of  the  functions  of  the  bladder 
and  rectum.  Exploration  of  the  jDclvis  tlien  reveals  a  large  mass  of 
exudation  not  sensitive  upon  pressure. 

Emmet  ^  has  called  attention  to  a  very  distressing  symptom,  hard  to 
relieve,  which  occurs  as  a  secjuel  after  the  acute  symptoms  have  passed 
away.  This  is  irritation  of  the  bladder,  with  a  constant  desire  to  urin- 
ate. The  cases  in  which  this  symptom  is  most  prominent  are  those  in 
which  the  cellular  tissue  of  the  utero-sacral  ligaments  has  been  involved. 
As  the  inflammation  subsides  and  the  ligaments  undergo  shortening, 
the  uterus  necessarily  becomes  antevertecl  to  an  abnormal  degree,  and 
as  the  cervix  is  carried  backward,  direct  traction  is  made  on  the  neck 
of  the  bladder ;  hence  the  bladder  symptoms.  The  phvsician,  not 
understanding  the  cause  of  this  irritation,  perhaps  resorts  to  injections 
into  the  bladder,  which  not  only  fail  to  afford  relief,  but  hasten  the 
occurrence  of  a  cystitis. 

To  relieve  this  distressing  symptom,  and  to  aid  indirectly  in  relieving 
the  inflammation  of  the  ligaments,  Emmet  has  devised  the  now  well- 
known  "  buttonhole  "  operation  on  the  urethra. 

Diagnosis. — The  clinical  history  of  periuterine  inflammation  is  so 
variable  that  in  a  verv-  large  proportion  of  cases  no  conclusion  as  to 
diagnosis  can  be  reached  except  by  a  study  of  the  physical  signs 
in  connection  with  the  circumstances  under  which  the  attack  occurs. 
This  study  involves  a  complete  knowledge  of  the  subject  of  pelvic 
exudations. 

The  diseases  which  must  be  differentiated  from  pelvic  cellulitis  are 
pelvic  peritonitis,  pelvic  hsematocele,  and  uterine  fibroids. 

The  differentiation  from  pelvic  peritonitis  is  the  most  important  and 
most  difiicult.  I  do  not  undertake  to  make  a  complete  diagnosis 
between  these  diseases,  but  simply  endeavor  to  present  here  and  in 
the  section  on  Pelvic  Peritonitis  such  points  as  will  aid  us  most  mate- 
rially in  coming  to  correct  conclusions. 

1  Op.  ciL,  p.  275. 


ri:Lvrr  cKLLri.iTis.  7ir> 

We  should  boar  in  iiiiiid  that  as  a  resuk  of  exudation  in  tlic  ninncc- 
tive  tissue  there  will  In-  at  first  merely  a  surface  (jf  rt-sistancc,  and  laicr 
a  firm,  doughy,  inelastic  swelling  of  rounded  outline  dis<-overal>l(;  in  one 
or  more  of  the  following;  Iwalitics: 

1.  Between  the  cervix  and  bladder  a  small  eircumscribed  iuHamma- 
tion  or  anti'-uterine  j)ldegmon  which  is  excessively  tender  to  the  touch, 
of  the  same  width  as  the  cervix,  and  does  not  extend  into  the  lateral 
euls-de-sac.  The  uterus  is  partially  fixed.  A  patient  inider  mv  care, 
while  carrying  an  armful  of  wood,  fell  astride  of  a  high  doorsill  in  stej)- 
ping  over  it,  thus  jarring,  wrenehing,  and  straining  hei*self  through  the 
pelvis.  She  suffered  severe  pain,  with  retching  and  vomiting  and  dis- 
tressing vesical  tenesmus,  and  the  exudation  was  as  above  described. 
Termination  in  resolution.  Suppuration  very  rarely  occurs,  and  the 
abscess,  as  in  the  case  seen  by  Courty,  empties  into  the  bladder.  This 
is  the  most  rare  of  the  phlegmons.     Traumatism  is  the  cause. 

2.  Between  the  cervix  and  the  rectum,  retro-uterine  phlegmon.  A 
circumscribcxl  swelling,  exquisitely  sensitive  on  pressure,  of  ellips<^id 
shape,  lying  transversely  behind  the  cervix,  differing  from  small  eff\i- 
sions  into  Dougla.s's  pouch  in  its  hardness  and  distinctness  of  outline, 
and  situated  at  a  higher  level  than  the  floor  of  this  pouch.  The  uterus, 
not  apprecialjly  displaced,  is  in  a  manner  fixed.  There  are  pelvic  j)aiu 
and  pain  in  defecation.  Sujipurating  phlegmons  here  are  rare.  The 
two  cases  of  Simon  and  A]])h.  Guerin  have  been  previously  referred  to, 
and  also  that  of  Xaudier,  the  last  illustrating  the  fact  that  quite  large 
abscesses  may  occur  in  this  location.  In  the  absence  of  an  autopsy  it 
■would  be  perhaps  impossiljle  in  such  a  case  as  Xaudier's  to  sav  whether 
the  effusion  was  in  the  cellular  tissue  or  in  the  peritoneum. 

3.  Phlegmons  of  the  parametrium  proper,  or  of  the  lateral  connec- 
tive tissue  at  the  junction  of  the  broad  ligaments  with  the  uterus,  form 
tumors  wdiich  are  of  semilunar  shape,  extending  from  one  side  ai'ound 
the  cervix  into  the  cellular  tissue  between  it  and  the  bladder,  or  to  the 
cellular  tissue  between  the  cervix  and  fossa  of  Douglas.  These  lateral 
phlegmons  are  to  be  distinguished  from  the  peritoneal  tumors  on  the 
sides  of  the  uterus  which  have  been  demonstrated  in  the  autopsies  of 
M.  Bernutz.  The  peritoneal  tumors,  which  consist  of  encvsterl  serous 
effusions  and  iuflammatorv  adhesions  behind  the  broad  ligaments,  from 
my  observation,  usually  seem  to  be  attached  to  the  womb  on  one  of  its 
postero-lateral  margins,  and  extend  from  about  the  level  of  theos  inter- 
num to  the  uterine  fundus  or  a  little  above  it.  They  are  most  easilv 
explored  through  the  rectum  after  throwing  the  womb  into  a  position 
of  moderate  retrovei-sion ;  which  can  often  be  done,  as  its  mobilitv  is  but 
partially  impairetl. 

In  addition  to  the  above  must  be  mentioned  the  exudations  into  the 
connective  tissue  of  the  folds  of  Douglas  or  utero-sacral   ligaments. 


716  PERIUTEBINE  INFLAMMATION. 

The  peritoneal  covering  of  these  folds  is  usually  involved  also,  and 
the  ligament  sometimes  becomes  converted  into  a  thick  retro-uterine 
tumor. 

4.  As  a  result  of  inflammation  originating  in  the  parametrium  the 
exudation  may  spread  along  the  base  of  the  broad  ligament  or  along 
its  upper  part,  or  may  involve  all  the  connective  tissue  between  its 
folds,  thus  forming  in  each  instance  a  well-marked  j)hlegmon  ^  sepa- 
rated from  the  uterus  by  a  distinct  furrow.  In  all  these  cases  the  uterus 
is  more  or  less  fixed,  and,  if  the  tumor  be  of  considerable  size,  is  pushed 
to  the  opposite  side  of  the  pelvis.  It  is  often  difficult  to  differentiate 
this  exudation  from  an  encysted  serous  pelvic  peritonitis  behind  the 
broad  ligament  and  pushing  it  forward.  In  some  cases  the  connective 
tissue  of  both  broad  ligaments,  the  entire  parametrium,  and  the  tissue 
of  the  utero-sacral  ligaments  are  completely  infiltrated  with  exudation- 
matter,  forming  a  solid  mass  around  the  womb  and  rendering  it  abso- 
lutely immovable.  Under  such  circumstances  it  will  be  sometimes 
observed  that  there  is  entire  absence  of  fever  and  entire  absence  of  pain 
or  tenderness  in  the  swelling;  and  we  may  be  certain  that,  as  a  rule, 
where  pain  has  been  absent  from  the  beginning  there  has  been  no 
involvement  of  the  peritoneum.  Fritsch^  attaches  great  value  for 
diagnosis  to  the  painless  origin  of  these  swellings. 

5.  The  tumors  described  under  the  foregoing  heads  are  small,  con- 
fined within  the  limits  of  the  true  pelvis,  and  do  not  rise  above  its 
brim.  The  inflammatory  process  may,  however,  after  travelling  between 
the  folds  of  the  broad  ligaments,  ascend  into  the  iliac  fossa  and  extend 
forward  underneath  the  peritoneum,  to  point,  in  the  event  of  su2:)pura- 
tion,  above  Poupart's  ligament ;  or,  extending  from  the  side  of  the 
uterus  around  the  latei'al  margin  of  the  bladder,  it  may  invade  the 
retro-pubic  tissue  and  ascend  on  the  anterior  abdominal  wall,  involving 
the  subperitoneal  connective  tissue  as  high  as  the  umbilicus,  and  forming 
an  abdomino-pelvic  tumor,  This  tumor  is  chiefly  abdominal,  but  pre- 
sents at  the  pelvic  roof,  and  can  be  easily  aspirated  through  the  vagina 
on  the  side  of  the  bladder.  It  is  not  median  in  situation,  but  formed 
rather  on  one  side  or  the  other  of  the  middle  line. 

In  these  cases,  though  the  tumor  does  not  descend  into  the  true  pel- 

^  A  description  by  Dr.  West  (Dis.  of  Women,  3d  ed.,  p.  423)  of  an  autopsy  made  by 
him  will  assist  the  student  in  obtaining  an  idea  of  the  composition  and  physical  cha- 
racteristics of  phlegmons  of  the  broad  ligament.  He  says:  "The  appearances  found 
after  death  explained  this  thickening  and  accounted  for  the  non-mobility  of  the  womb, 
for  the  folds  of  the  broad  ligament,  from  the  upper  part  of  the  vagina  to  the  lower 
surface  of  the  ligamentum  ovarii,  enclosed  a  mass  of  dense  cellular  tissue  of  almost 
cartilaginous  hardness,  crying  under  the  knife,  dense  white  bands  intersecting  each 
other  in  all  directions  and  having  a  firm  yellow  fat  between  them.  This  mass  was 
closely  adherent  along  the  whole  left  side  of  the  uterus,  though  the  uterine  tissue  was 
in  no  i"espect  implicated  in  it." 

2  Op.  ciL,  p.  272. 


rin.vic  ci'.i.i.rLiTis.  717 

vis,  we  will  cxpccl  lo  liiid  csidriiccs  ol'  iiill:iiiiiiiMl  Ion  nc.ir  llic  iitcni< — 
that  is,  ('MKlalidii-iiKittcr— and  some  lixatimi  nl'llial  ortiaii,  and  in  lia\X' 
the  aiid'cfdt'iit  histdiy  ol"  lahttr  or  al>oi-lioii. 

Ivai'cK',  (lie  phlcii'iuoiis  run  their  conix'  willmiil  a  .-Ninplnm  <it'  |)<ri- 
toiiilis  diii'inij,'  lill'  oi"  a  [\\\rv  ol"  il  after  death,  as  |»ii)\-en  l)\'  a  lew 
autopsies.  Often  |)ei"i(onitis,  to  a  iiiodcralc  c.rfciit,  coexists  with  the 
phlei;inon,  hut  to  so  slight  a  (le<;'ree  that  the  attack  is  practically  one  of 
cellnlitis.  In  sevei'c  attacks  the  two  din^ases  nsnally  pi'e\ail  in  nearlv 
e(|iial  intensity.  'J'hen  the  diai^nosis  must  he  pei'iuterine  inllannnalion. 
Occasionally,  a  sejitic  ])efitonitis  destroys  life  in  a  few  days  without  any 
in\"olvcinciit  of  the  ceilnlar  tissne. 

The  sti'onLi;  j)oints  in  favor  of  a  tunioi'  heino;  dtio  to  cellnlitis  are  its 
sequence  npon  lahor  or  ahortion  or  a  snru'ical  operation  upon  the  cervix 
uteri  ;  its  appearance  in  one  of  the  localities  in  which  the  cellular  tissue 
ahoiuids  ;  its  unilateral  position;  its  comparatively  ])ainless  ori^-in  ;  and 
its  freedom  from  tenderness  on  pressure.  These  may  be  termed  proha- 
bilities  of  diaii'nosis.  In  protracted  cases  there  is  a  luarked  tendency  in 
cellular  tumors  to  suppurate;  in  peritoneal  tumors,  to  monthly  exacer- 
bations. 

Tumors  which  result  from  peritonitis  alone  occupy  two  })ositions. 
One  of  these  is  in  Douglas's  pouch,  where  it  can  be  felt  encroaching 
upon  the  vagina  and  rectum,  and  pushing  the  uterus  forward  and 
upward  against  the  pubic  bone.  The  second  position  is  in  one  of  the 
lateral  ])ositions  called  by  Polk  the  "retro-ovarian  shelves." 

Absolute  immobility  of  the  uterus  is  often  observed  in  connection 
with  peritoneal  tumors,  while  in  cellulitis  uterine  mobility  is  less 
impaired. 

Courty  says  that  peritoneal  tumors  are  "  never  indolent ;"  acute  i)ain 
accompanies  their  formation,  and  they  are  very  sensitive  upon  pressure. 
(For  further  remarks  on  diagnosis  the  reader  is  referred  to  the  section 
on  Pelvic  Peritonitis.) 

Pelvic  Hcematocek. — An  intraperitoneal  ha^matocele  could  scarcely  be 
confounded  with  ]ielvic  cellulitis.  It  is  difficult  under  some  circum- 
stances to  differentiate  a  retro-uterine  htematoccle  from  a  pelvic  ])eri- 
tonitis  in  which  there  is  an  encysted  effusion  in  Douglas's  pouch  ;  but 
the  hist(M'y  of  the  case  usually  removes  all  doubts  of  diagnosis.  Aspira- 
tion would  not  be  advisable  for  diagnostic  j)urposes. 

It  is  only  in  the  pelvic  haematoma  of  Bernutz,  or  ha?matocele  in 
Avhich  the  bloody  effusion  has  occurred  in  the  connective  tissue  of 
the  broad  ligament,  that  the  physical  signs  resemble  those  of  pelvic 
cellulitis. 

In  this  affection  there  is  a  history  of  abrupt  invasion,  sudden  forma- 
tion of  tumor,  without  fever  or  symptoms  of  inflammation  ;  the  tumor 
is  in  the  broad  ligament,  the  anterior  wall  of  which  is  bulging;  the 


T18  PERIUTERINE  INFLAMMATION. 

tumor  is  at  first  jfluid,  and  in  a  few  days  becomes  solid ;  the  uterus  is 
fixed.  After  a  time,  when  absorption  has  occurred,  the  base  of  the 
ligament  is  felt  like  a  firm  cord  running  out  to  the  pelvic  wall. 

I  have  several  times  diagnosed  such  cases,  and  Emmet ^  has  reported 
one  in  which  the  wall  of  the  hsematoma  ruptured  and  blood  was 
extravasated  into  the  peritoneum. 

Uterine  Fibroids. — The  tumor  formed  by  an  interstitial  fibroid  is  one 
with  the  uterus,  and  cannot  be  separated  from  it  by  any  line  or  furrow 
of  demarkation.  A  subperitoneal  fibroid  growing  from  the  posterior 
wall  of  the  uterus,  and  pushing  it  against  the  pubic  bone,  might  be 
confounded  with  a  parametritic  exudation.  Fritsch^  reports  such  a 
case  in  which  the  diagnosis  was  very  difficult.  When  the  truth  was 
revealed  by  autopsy,  instead  of  a  parametritic  suppurating  exudation 
there  ^vas  found  a  sloughing,  incarcerated  myoma  of  the  posterior 
cervical  wall.  It  must  be  remembered  that  large  parametritic  exu- 
dations behind  the  uterus  are  very  rare, 

Peogxosis, — In  discussing  prognosis  reference  is  here  made  not  only 
to  the  probable  course  of  the  inflammation,  but  to  its  remote  conse- 
quences. Both  recent  and  chronic  inflammations  of  the  cellular  tissue 
generally  result  in  recovery.  Both  puerperal  and  non-puerperal  cases 
cause  anxiety  in  proportion  to  the  prominence  of  the  septicsemic 
symptoms.  The  inflammation  may  entirely  disappear,  and  yet  its 
results  may  be  of  the  most  baneful  character. 

Pelvic  cellulitis  may  give  rise  to  the  following  morbid  conditions, 
which  are  oftentimes  practically  irremediable : 

1.  Pathological  Anteflexion,  the  cervix  being  drawn  upward  and 
backward,  and  the  fundus  thrown  forward.  The  uterus  itself  is  drawn 
away  from  the  pubes  and'  nearer  to  the  sacrum.  As  shown  by  Schultze, 
this  is  due,  first,  to  inflammation ;  then  resolution  with  cicatrization  and 
contraction  of  the  tissue  between  the  peritoneal  folds  which  constitute 
the  utero-sacral  ligaments.  Thickening  and  resistance  of  the  structures 
in  the  neighborhood  of  one  or  both  of  these  ligaments  are  aj^preciable 
by  the  finger.  Dysmenorrhoea,  sterility,  and  obstinate  cystitis  fre- 
quently result  from  these  changes  in  the  ligaments. 

2.  Lateral  Version  is  a  result  of  cellulitis  between  the  folds  of  one 
broad  ligament.  After  resolution,  contraction  follows  and  the  uterus 
is  drawn  to  that  side. 

3.  Disorders  of  Menstruation:  Amenori'hoea  and,  3Ienorr]iagia. — 
Emmet  has  shown  by  analysis  of  his  cases  that  menstruation  remained 
normal  in  about  16  per,  cent,  only. 

Other  consequences  have  been  ascribed  to  cellulitis,  but  they  are  for 
the  most  part  attributable  to  the  peritonitis  which  so  often  complicates  it. 
Treatment, — Prophylaxis. — The  prophylactic  treatment  of  a  dis- 
1  Op.  cit.,  p.  233.  '  Op.  cit.,  p.  273. 


PKI.Vlc  cELI.ri.lTIS.  7I<, 

ejiso  wliii'h  is  trcncrally  coiisidci-cil  in  l)c  lor  ilw  most  part  of  septic 
ori'^'iii  must  practically  cinisist  in  the  ri<;i»l  adoption  of"  those  measures 
which  ha\('  l)ccn  i'onnd  to  he  most  efficient  in  preventin<r  tlie  admission, 
of  poisonous  germs  from  without,  to  the  tissues  wjilcli  liave  been  laid 
o|)en  l)v  tlie  injuries  done  to  the  genital  canal  ilnring  parturition,  or  hv 
the  kiiit'c  ot"  the  surgeon  in  the  various  procedun^s  of  gvnecologv. 

Tlic  strictest  eleaidiness  must  therefore  charaeterizo  all  obstetrical  and 
surgical  manipulations — cleanliness  of  the  entire  person  of  the  ojU'rator 
and  of  his  insti-uments  and  dressings;  the  av^oidanee  of  unnecessary 
examinations  of  the  genital  passages  during  parturition;  the  frequent 
ablution  of  the  hands  and  bathing  of  the  external  genitals  during  labor 
with  antiseptic  solutions;  and  antiseptic  irrigation  of  the  vagina  in 
gynecological  oj)erations. 

The  most  thorough,  rational,  and  efficient  system  known  to  us  for 
obstetric  cases  is  that  Mhich  was  introduced  into  the  Xew  York  ^Nlater- 
nity  H()S]>ital  in  1883  by  Dr.  H.  J.  Garrigues/  and  which  is  identical 
Avith  that  adopted  two  years  later  by  the  staff  of  the  Boston  Lying-in 
ll(>sj)ital.-  This  method  is  based  upon  the  theory  of  the  bacteriologists, 
that  the  septic  poison  is  not  autogeuetic,  but  that  the  germs  are  intro- 
duced from  Avithout.  Its  great  value  may  be  inferred  from  the  fjiet 
that  since  its  adoption  the  percentage  of  sepsis  in  the  Xew  York  ^later- 
nity  has  been  reduced  from  6  to  .21  per  cent.,  while  in  the  Boston  Hos- 
pital a  similar  reduction  has  been  obtained.  A  part  of  this  system  con- 
sists in  the  careful  and  accurate  closure  of  perineal  lacerations.  "  Wlien 
Ave  have  secured  complete  primary  adhesion  in  a  recent  wound,  as  a  rule 
all  danger  from  inflammation  is  at  an  end."^  While  the  application  of 
this  principle  is  easy  enough  for  lacerations  of  the  lower  portion  of  the 
vagina,  it  is  surrounded  by  some  embarrassments  where  the  cervix  uteri 
is  involved.  And  yet  in  sjiecial  cases  Avliere  extensive  cervical  lacera- 
tion has  occurred  it  should  be  repaired  in  the  same  manner  very  soon 
after  the  termination  of  the  labor. 

This  principle  I  have  put  to  a  practical  test  in  a  most  conclusive  case 
of  extensive  laceration  involving  the  entire  cervix  on  one  side,  extend- 
ing upward  beyond  the  os  internum  and  laterally  into  the  vaginal 
roof.^ 

Gynecological  operations  up<^n  the  non-puerperal  woman  should  be 
conducted   with  the  strictest  antiseptic  precautions. 

Cnrnficr  Treatment. — In  the  beginning  of  an  attack  of  ]iclvic  cellu- 
litis the  first  indication  of  treatment  is  to  relieve  pain  and  bring  about 

'  Antiseptic  Midwifery,  by  H.  .T.  Garrijjiies,  ]886. 

*  "  Antiseptics  in  Obstetric  Practice,"  by  W.  L.  Richardson,  Boston  Med.  and  Surg, 
Journ.,  Jan.  27,  1887. 

"  Internat.  Encyrlopfrd.  of  Surgery,  "Inflammation,"  vol.  i.  p.  140. 

*  Mix!<.  Valley  ^[erl.  Mnnthly.  Dec,  1884,  "An  Important  Point  in  the  Prevention  of 
Pelvic  Inflammation  alter  Delivery." 


720  PERIUTERINE  INFLAMMATION. 

reaction  as  quickly  as  possible.  Both  these  objects  will  be  accomplished 
by  the  administration  of  opium  and  the  external  application  of  heat. 
If  the  attack  be  of  moderate  severity,  the  opium  may  be  given  by  the 
mouth  or  rectum  in  doses  sufficient  to  relieve  pain  ;  and  its  use  should 
be  judiciously  continued  as  long  as  the  patient's  comfort  actually  requires 
it.  The  good  effects  of  heat  are  best  obtained  by  the  application  to  the 
abdomen  of  flannels  wrung  out  of  hot  water.  These  should  be  renewed 
as  often  as  they  become  cool,  and  at  the  same  time  copious  hot-water 
vaginal  injections  may  be  administered. 

Absolute  rest  of  body  and  mind  should  be  secured  from  the  begin- 
ning, and  should  be  continued  until  convalescence  is  established. 

In  cases  of  great  severity  there  are  usually  decided  chill,  and,  as  the 
peritoneum  is  involved,  acute  pain.  The  pulse  rapidly  rises  to  120  and 
upward,  and  the  clinical  thermometer  registers  104°  to  105°  F.  The 
patient  is  in  great  distress.  Under  these  circumstances  prompt  and 
active  treatment  is  demanded.  The  pain  should  be  relieved  by  hypo- 
dermic doses  of  morphia.  The  temperature  should  be  reduced  to  near 
the  normal  by  proper  doses  of  antipyrine.  As  the  tendency  in  such 
cases  is  to  a  continuance  or  to  a  return  of  high  temperature,  the  two 
other  antipyretic  agents,  cold  and  quinine,  may  be  required.  After  the 
temperature  has  been  reduced  by  antipyrine,  quinine,  in  full  doses  by 
the  stomach  or  by  the  rectum,  is  of  decided  value,  especially  in  those 
cases  marked  by  decided  remissions. 

The  two  objects  to  be  aimed  at  are  the  relief  of  pain  and  the  main- 
tenance of  a  nearly  normal  temperature  by  the  use  of  one  or  all  of  the 
antipyretics  combined.  To  accomplish  these  will  require  unremitting 
attention  for  days.  MeauAvhile,  the  patient  should  be  nourished  by 
liquid  food  as  well  as  the  stomach  will  permit. 

After  the  fever  has  subsided  the  most  important  work  to  be  accom- 
plished is  removal  of  the  exudation.  The  successful  accomplishment 
of  this  depends  upon  a  proper  performance  of  the  nutritive  functions ; 
hence  the  condition  of  the  digestive  organs  must  be  carefully  observed. 
From  time  to  time,  calomel  in  one-grain  or  half-grain  doses,  given  once 
in  three  hours  to  the  extent  of  three  or  four  grains,  will  be  of  great 
value  in  modifying  the  secretions  and  in  acting  as  a  safe  aperient.  For 
the  relief  of  the  gastric  catarrh  and  other  symptoms  of  impaired  diges- 
tion so  common  in  febrile  disorders,  I  have  often  used  before  meals  a 
teaspoouful  or  less  of  an  alkaline  powder  composed  of  equal  parts  of 
the  phosphate  of  lime,  subnitrate  of  bismuth,  and  magnesia.  This  aids 
digestion  and  generally  secures  a  daily  movement  of  the  bowels.  Emmet 
recommends  five  grains  of  inspissated  ox-gall  three  times  a  day. 

When  convalescence  begins  the  patient  should  be  fed  as  liberally  as 
her  digestive  powers  will  alloAV,  and  these  will  be  greatly  aided  by  ton- 
ics, among  which  the  citrate  of  iron  and  quinia  may  be  mentioned  as 


PKLVrr  AIISCESS.  7-2] 

especially  u-;(t"iil.  <  )|miiiii  may  \tv  rc'(|tiirc(l  in  small  doses  f«»r  a  r-onsid- 
craMc  pt'iMfMl.  It  >ji()iil(l,  however,  be  tliscon tinned  as  soon  as  tlie 
patient's  cnnditinn    will   allow    ii. 

l''or  hiL-iteninj:;  the  al)sorj)tion  of  the  exndation  a  blister  across  the 
livpoi;iistriiim  will  be  of"  decided  valne.  This  may  be  repeated  in  ten 
ov  twelvi-  (lavs  it'  cireunistanees  recpiire  it. 

The  hot  vajiinal  douche,  as  recommended  by  Emmet,  is  of"  great 
valne  in  stimulating  the  removal  of  inflammatory  products. 

In  cases  which  are  disj)osed  to  a.ssume  a  chronic  character  repeated 
blisters  are  called  for ;  and  we  may  derive  much  benefit  from  the  use 
of  the  wet  bandage  around  the  hips  and  abdomen.  It  should  be  cov- 
ered with  rubber  cloth  and  worn  continuously  day  and  night.  It 
lessens  internal  congestions  and  relieves  pelvic  pain  and  soreness. 

Should  the  system  fail  in  its  efforts  to  accomplish  removal  of  the  exu- 
dation, a  new  train  of  symptoms  will  arise,  indicating  the  formation  of 
pus. 

Pelvic  Abscess. 

Etiology. — Pelvic  abscess  in  women  is  for  the  most  part  the  result 
of  some  one  of  the  forms  of  periuterine  inflammation  which  have  been 
described  in  the  preceding  pages.  It  is  true  that  now  and  then  a  col- 
lection of  pus  is  found  in  the  female  pelvis,  as  in  the  male,  in  conse- 
quence of  an  inflammation  of  the  bones  which  enter  into  the  formation 
of  the  sacro-iliac  sympliysis.  Such  a  collection  may  also  result  from 
the  extension  of  a  psoas  abscess,  or  it  may  originate  in  the  cellular  tissue 
between  the  rectum  and  sacrum  in  consequence  of  traumatism,  or  as  a 
result  of  those  textural  changes  which  are  so  ready  to  occur,  in  depraved 
conditions  of  the  blood,  in  the  cellular  tissue  of  anv  portion  of  the 
body.  The  collections  of  pus  here  alluded  to  are,  however,  of  rare 
(K'currence,  and  we  shall  not  be  far  from  right  in  declaring  that,  j)rac- 
tically,  pelvic  absce-ss  in  the  female  is  directly  traceable  to  two  causes — 
1st,  pelvic  peritonitis;  2d,  pelvic  cellulitis,  or  else  to  both  these  inflam- 
mations combined. 

In  any  given  case  it  will  usually  ])e  an  easy  matter  to  prove  that  the 
abscess  has  resulted  from  an  inflammation  which  had  its  beginning  in 
or  near  the  uterus.  This  will  be  made  evident  by  the  historv  of  the 
case,  by  fixation  of  the  uterus,  and  by  the  presence  of  exudation-matter 
located  near  it  and  extending  continuously  to  the  seat  of  the  abscess. 
There  need  not  be  continuity  of  supj)uration  from  the  uterus  to  the 
abscess.  The  uterine  lesion  may  originate  an  inflammation  which  will 
be  pro])agated  along  the  lymphatics  to  the  lymphatic  gan<rlia  remote 
from  the  uterus.  The  connective  tissue  around  these  ganglia  mav  then 
become  inflamed,  and  thus  the  abscess  is  formed  at  some  distance  from 
the  uterus. 

Vol.  I. — 46 


722  PERIUTERINE  INFLAMMATION. 

In  addition  to  these  purulent  accumulations  in  the  pelvic  cellular  tis- 
sue and  peritoneum  there  are  several  others  which  require  mention  only 
in  this  place.     These  are — 

1st.  Pyosalpinx,  which  sometimes  forms  a  distinct  tumor. 

2d.  Abscess  of  the  ovary,  which  as  a  separate  and  distinct  aifection 
is  occasionally  met  with  in  the  non-puerperal  woman.  It  is  supposed 
to  be  of  very  rare  occurrence,  and  is  probably  caused  by  long-continued 
ovarian  irritation  the  result  of  some  form  of  uterine  disease,  such,  for 
example,  as  fibroid  growths.  Mr.  Henry  Morris,^  Mr.  C.  J.  Culling- 
worth,^  Mr.  Lawson   Tait,^  and  Dr.    Emmet  *  have  recorded  cases. 

3d.  Abscess  of  the  uterus  or  circumscribed  abscess  in  the  walls  of 
the  uterus  has  been  recorded  by  Scanzoni,  Schroeder,  and  others. 

In  destructive  puerperal  inflammations  which  involve  all  the  tissues 
of  the  pelvis  it  is  not  very  uncommon  to  find  an  abscess  located  in  the 
uterine  parenchyma.  Dr.  Robert  Barnes^  says  the  abscess  does  not 
originate  there,  but  may  be  traced  to  "  foci  foi^med  in  the  venous  tissues 
or  lymphatics,  whose  walls  are  first  inflamed  by  the  reception  of  septic 
matter  from  the  cavity  of  the  uterus."  Outside  of  this  condition  it  is 
questionable  if  abscess  of  the  uterus  is  ever  met  with.  Mr.  Tait^  has, 
however,  described  a  case  which  he  diagnosed  as  such  in  a  non-puerperal 
subject  after  exposure  to  cold.  The  purulent  collection  was  at  the  base 
of  the  bladder,  intimately  associated  with  the  uterus  and  movable  with 
it.  After  the  cervix  had  been  dilated  by  a  tent  the  uterine  cavity  was 
found  to  be  filled  with  pus,  and  the  finger  detected  on  the  anterior 
uterine  wall,  just  within  the  cervix,  a  soft  spot  with  an  aperture  in 
its  centre.     The  patient  recovered. 

Pathological  Anatomy. — Intraperitoneal  accumulations  of  pus  ex- 
ceed in  pathological  importance  all  other  pelvic  abscesses  for  the  follow- 
ing reasons  :  They  are  of  common  occurrence,  often  of  large  size,  cause 
profound  disturbance  of  the  nutritive  functions,  and,  surgically  con- 
sidered, are  usually  very  difficult  of  access.  In  some  instances  they 
show  but  little  tendency  to  empty  themselves,  and  may  be  carried  by 
the  patient  for  aii  indefinite  period. 

If  rupture  occurs,  it  may  be  into  the  peritoneum,  and  give  rise  to  a 
rapidly-fatal  peritonitis ;  or  else  into  the  rectum,  and  cause  an  exhaust- 
ing and  uncontrollable  diarrhoea ;  or  it  may  lead  to  the  formation  of 
extensive  fistulous  tracts,  which  are  always  difficult  to  close  and  some- 
times entirely  beyond  the  reach  of  surgical  art.  Dr.  Matthews  Dun- 
can said  in  1 868  :  "  I  regard  intraperitoneal  purulent  collections  as 
forming  the  majority  of  the  grave  abscesses  in  this  situation." 

The  intraperitoneal  abscess  has  a  cavity  of  indescribable  shape,  with 

1  Bi-U.  Med.  Joum.,  May  21,  188L  '  Lancet,  Nov.  3  and  10,  1877. 

3  Diseases  of  Ovaries,  4th  ed.,  p.  125.  ^  Op.  cit.,  p.  651. 

5  Med.  and  Surg.  Bis.  of  Women,  1874,  p.  439.  ^  Diseases  of  Women,  p.  64. 


ri:iA'l('  ABSCESS.  72:i 

miiiu'nms  |i(>ii<'lic,-,  t>i-  j»i(icc»(>  riiiiiiiii|j,-  in  dilliTcnt  dircclioiis.  Its 
walls  are  c*uiii[K)st'(l  of  false  inciubraiies,  of  coils  of  intestine,  of  perhaps 
the  sit2;inoi(l  Hexure  and  reetnni,  and  of  the  hroad  li<jfain(;nt  on  one  side. 
In  its  centre,  as  Aran  sttites,  there  is  «2;enerally  I'onnd  one  otthe  uterine 
appenda»!;es  or  the  ovarv  and  tnl)e  of  one  side. 

Thi'  most  important  feature  of  peritoneal  al)S(!e.s-^es  is  that  at  some 
point  within  the  ahscess-cavity  we  are  quite  sure  to  have  the  I''allopian 
tube  ilistended  with  j)us.  Here,  then,  is  an  abscess  within  an  al)S((-s. 
Althou>!;h  the  abscess  [)roper  may  be  evacuated  by  rupture  or  the  knii'e, 
a  eiu'e  is  delayed :  the  foim  et  or'ir/o  ina/i  is  not  destiv)yed.  This  I 
believe  to  be  a  great  difficulty  in  the  way  of  bringing  about  the  closure 
of  these  cavities. 

Coming  next  to  consider  absc^^^scs  of  the  cellular  tissue,  it  may  be 
stated  that  wherever  this  tissue  abounds  suppuration  may  occur,  and 
may  extend  frohi  its  point  of  origin  throughout  the  pelvis.  Pas 
will  extend  in  the  direction  of  the  least  resistance.  The  influences 
which  guide  its  extension  are  the  planes  of  fasciae  and  the  course 
of  the  lymphatic  vessels,  which  are  the  chief  poison-carriei's.  The 
pus  is  often  not  confined  in  a  single  cavity,  but  the  abscess  is 
multilocnlar. 

Dr.  Thomas  Savage  ^  states  that  these  abscesses  have  burst  or  been 
opened  in  order  of  frequency — 1,  in  the  iliac  region ;  2,  above  the  pubes, 
nearly  as  high  as  the  navel ;  3,  in  the  inguinal  region  ;  4,  by  the  side 
of  the  anus ;  5,  by  the  vagina ;  6,  by  the  rectum ;  7,  into  the  bladder ; 
8,  into  the  peritoneum. 

According  to  Winckel,^  from  an  analysis  of  24  cases  of  puerperal 
pelvic  cellulitis  of  his  own  and  13  by  Veit,  suppuration  occurred  in  6. 
He  quotes  Konig  as  saying  that  opening  under  Poupart's  ligament  Avas 
the  most  frequent  course ;  sometimes  through  the  abdominal  wall  above 
Poupart's  ligament ;  then  into  the  rectum ;  then  into  the  bladder  and 
vagina;  while  that  into  the  uterus,  through  the  perineum,  greater 
sciatic  foramen,  into  the  peritoneum,  and  alongside  the  quadratus  lum- 
borum  muscle,  are  equally  rare. 

As  to  the  frequency  of  abscess  of  the  broad  ligament  discrepancy  <jf 
opinion  exists.  Thus,  Courty  ^  says  that  abscess  of  the  broad  ligament 
is  common.  Dr.  W.  H.  Byford  *  says  :  "  The  most  frequent  locality  of 
pelvic  abscess  is  between  the  layers  of  the  broad  ligament."  On  the 
other  hand,  Dr.  ^latthews  Duncan '  says  that  abscess  of  the  broad 
ligament  "is  very  fir  from  common,"  and  that  "  the  broad  ligaments 
are  not  parts  in  which  inflammation  and  abscess  are  likely  to  take  their 
origin."     He  alludes  to  the  fact  that  the  pus  between  the  layers  of  the 

»  Op.  cit.,  1870.  2  Qp  „7^  p  209. 

'  Op.  cit.  *  Tram.  Amer.  Gynecolog.  Soc,  vol.  viii.  p.  209. 

5  Op.  cU.,  p.  29. 


724  PERIUTERINE  INFLAMMATION. 

broad  ligament,  described  in  puerperal  autopsies  by  old  physicians,  was 
not  in  an  abscess,  but  in  the  veins  or  lymphatics. 

Dr.  Thomas  Savage,  in  his  work  on  the  Anatomy  of  the  Female  Pel- 
vie  Organs,  whilst  recording  the  forms  and  localities  of  20  cases  of  pel- 
vic abscess,  mentions  only  2  in  which  the  broad  ligament  was  the  seat 
of  the  abscess.  In  1  of  these  there  existed  a  uterine  fibroid.  Perito- 
nitis and  death  resulted  from  rupture  of  a  large  abscess  of  the  broad 
ligament.  In  the  second  case  a  uterine  polypus  had  been  removed  by 
the  ligature.  Death  followed  rupture  into  the  peritoneum  of  a  large 
abscess  of  the  broad  ligament. 

Dr.  D.  Berry  Hart  ^  remarks :  ''  There  is  little  doubt  that  we  can 
have  a  cellulitis  of  the  broad  ligament,  and  that  it  may  go  on  to  abscess 
of  the  broad  ligament.  This  I  have  seen  in  a  case  of  abdominal  section 
by  Prof.  A.  P.  Simpson,  where  the  existence  of  pus  distending  the 
broad  ligament  was  verified  by  the  aspirator  passed  "in  from  above." 

From  my  own  observation  I  would  say  that  abscesses  of  the  broad 
ligament  are  far  from  common. 

Some  pelvic  abscesses  have  their  origin  in  extraperitoneal  hsemato- 
celes  or  hsematomata  in  the  cellular  tissue  of  the  broad  ligaments.  This 
has  been  proven  by  Mr.  Tait's  operations,  in  which  the  abscess  wall  was 
chiefly  formed  at  the  expense  of  the  posterior  layer  of  one  of  the  broad 
ligaments.  The  floor  of  the  abscess-cavity  was  organized  blood-clot ; 
the  contents  were  fetid  pus  and  decomposing  blood-clots. 

The  evacuation  of  the  contents  of  an  abscess  frequently  fails  to  result 
in  a  cure.  In  the  event  of  rupture  into  the  rectum  or  bladder  there 
may  be  an  almost  uninterrupted  discharge  of  pus  through  either  of 
these  cavities  for  months.  In  a  case  under  my  care  the  purulent 
accumulation  was  on  the  right  side  of  the  pelvis,  and  rupture  occurred 
into  the  rectum.  The  patient  refused  all  manner  of  surgical  assistance, 
and  the  discharge  of  pus  through  the  rectum  continued  with  slight 
interruptions  for  four  years. 

The  explanation  of  such  cases  is  to  be  found  in  the  facts  that  the 
opening  is  often  oblique  or  indirect,  and  is  not  so  situated  as  to  com- 
pletely empty  the  abscess-cavity ;  the  walls  have  become  thickened  and 
otherwise  changed ;  granulations  do  not  form  and  the  adhesion  of  oppos- 
ing surfaces  fails ;  moreover,  one  of  the  diseased  uterine  appendages 
remains  to  keep  up  the  inflammation.  Fistulous  canals  result.  This 
leads  us  to  consider — 

The  Structure  of  the  Walls  of  Abscess- Cavities. — The  lining  mem- 
brane of  acute  abscesses,  Avherever  they  may  exist,  consists  simply  of 
true  granulation-tissue,  such  as  we  see  covering  the  surface  of  a  wound 
Avhich  is  undergoing  the  process  of  healing.  The  abscess-cavity  is 
obliterated  partly  by  the  formation  of  granulation-tiasue,  and   partly 

'  Atlas,  plate  xxii. 


ri'i.vic  A!:sci-:ss.  7-J') 

l)v  the  adlit'sloii  ot"  ()|»|)(i-iiiu'  t:i'aiiiil;ili(iii-siii'l";iccs.  'To  >cciirr  ul»liicr:i- 
tion  of  this  cavitv  coiiiplctt'  cNafiiatioii  and  cf)!!!!!!!!!-!!  tlniiiia<;o  are 
r('(|iiir('(l,  and  il'  the  cavitv  is  a  lari^c  one  u  licaltliy  coiiditiKii  of  the 
milfiti\t'   fiiiictioiis   is  also  essential. 

According;  to  A_<;no\v/  the  cncapsidatiiiti;  wall  of  a  chronie  abscess 
dilli'i's  from  that  of  the  acute  only  "  in  tliicUiicss,  stn'n<:th,  and  devel- 
opment." ....  "  Mneh  of  the  inllannnatorv  ti"ansndati(tn  is  org-aiiized 
into  connective  tissue,  so  that  tiiis  wall  ix-comes  a  iihrons  sac,  sometimes 
of  ureat  thickness."  ....  "The  exterior  of  this  wall  or  sac  is  'wve^r- 
idar,  bristling-  with  prolongations  which  interj)enetrate  the  sin'ronndiii<; 
parts,  while  the  interior  has  a  villous  or  irraiudar  aj)pearance,  the  emi- 
nences consistinj^  of  h)()j)S  of  blood-vessels  buried  in  transudation-cor- 
puscles.  These  vessels  are  the  source  of  the  leucocytes  which  form  the 
pus  of  the  abscess,  the  conne(^tive  tissue,  at  least  in  several  localities, 
plavintji:  a  very  subordinate  part  in  its  production." 

Dr.  William  H.  Byford"  of  Chicau;o  has  made  a  very  interesting  con- 
tribution to  our  knowledge  of  the  changes  which  take  place  in  the  walls 
of  the  cavities  of  some  chronic  pelvic  abscesses.  Dr.  Byford  says:  "At 
first  the  inner  wall  of  the  cavity  is  covered  with  the  healthy  gramda- 
tions  of  an  ordinary  ulcer,  and  in  every  respect  resemble  those  observed 
in  external  ulcerations.  After  an  indefinite  time  they  degenerate  and 
disappear,  when  patches  of  cicatrization  residt,  and  in  the  end  the  whole 
cavitv  is  lined  with  a  cicatricial  membrane.  With  the  loss  of  the  gran- 
ular character  of  the  inner  surfiice  no  more  pus  is  produced.  The  lin- 
ing of  the  wall  is  no  longer  covered  with  granular  eminences,  but  it  is 
a  smooth,  shining  membrane  of  cicatricial  organization.  This  membrane 
is  then  of  the  simplest  organization,  and  possesses  the  properties  of  ex- 
osmosis  and  endosmosis.  The  cavity  is  kept  in  a  state  of  repletion  by 
exosmosis,  and  sometimes  grows  by  an  excess  of  serum  thus  effused  ; 
generally,  however,  an  equilibrium  in  these  two  processes  maintains  sta- 
tionary dimensions  in  the  tumor  thus  resulting." 

Dr.  Byford  thinks  the  changes  here  described  explain  the  origin  of 
some  of  the  cvstic  tumors  of  the  abdomen  and  pelvis  which  have  been 
reported  by  Dr.  George  H.  Bixby.^  lie  was  cognizant  for  a  number 
of  years  of  the  progress  of  two  of  the  tumors  alluded  to  in  Dr.  Bix- 
by's  article. 

This  author  oroes  on  to  state  that  "the  linino;  of  the  walls  of  the 
chronic  abscesses  does  not  speedily  undergo  the  changes  thus  describeil ; 
but  from  it  may  be  found  dei)ending  masses  of  granulations,  giving 
rise  to  tag-like  projections  in  great  numbers,  from  the  twentieth  of  an 
inch  to  half  an  inch  or  more  in  length.  In  all  instances  in  Avhich  I 
have  observed  these  projections  they  have  proved  too  fragile  to  be  con- 

'  Principles  and  Practice  of  Sur(/ery,  vol.  i.  p.  105. 

*  Trans.  Am.  Gyti.  Soc,  vol.  viii.  '  Ibid,  vol.  i. 


726  PERIUTERINE  INFLAMMATION. 

sidered  fibrinous  exudations,  and  have  possessed  all  the  properties  of 
aggregated  granulation-masses.  They  are  fungoid  and  easily  broken 
down  and  removed  by  the  finger  or  dull  curette." 

Diagnosis. — The  diagnosis  of  pelvic  abscess  involves  the  recognition, 
first,  of  an  inflammatory  exudation  in  the  pelvis,  and  secondly,  of  the 
occurrence  of  suppuration. 

Pelvic  exudations  are  usually  associated  with  a  well-marked  history 
of  periuterine  inflammation.  They  have  already  been  discussed  in  this 
connection  in  the  preceding  sections.  Sometimes,  however,  the  exuda- 
tion process  is  a  cold  one  throughout  its  entire  history;  the  usual  symp- 
toms of  inflammation  are  absent ;  the  patient  is  at  no  time  confined  to 
bed ;  a  large  tumor  fills  the  pelvic  cavity ;  and  then  for  a  time  the 
diagnosis  may  be  obscured.  In  some  instances  the  tumor  thus  formed 
is  easily  confounded  with  a  uterine  fibroid. 

The  occurrence  of  suppuration  in  sthenic  cases  is  marked  by  rigors 
and  fevers  of  the  hectic  type,  the  temperature  rising  high  in  the  even- 
ing and  subsiding  after  midnight  with  a  sweat.  There  are  also  added 
increased  pain  in  the  swelling  and  fluctuation. 

In  other  cases  no  such  symptoms  arise.  Weeks  pass  by.  The  patient 
suffers  but  little,  yet  convalescence  does  not  occur.  The  exudation-mass, 
instead  of  slowly  melting  away,  remains  unchanged  or  perhaps  increases 
in  extent.  Fixation  of  the  uterus  continues.  The  appetite  does  not 
improve.  Nutrition  steadily  fails.  Careful  examination  with  the  ther- 
mometer now  reveals  a  slight  increase  of  the  bodily  temperature  above 
the  normal,  and  the  physician  is  thus  led  to  suspect  the  occurrence  of 
suppuration.  Still,  fluctuation  may  be  inappreciable ;  and  this  is  espe- 
cially apt  to  be  so  if  the  effusion  is  above  the  pelvic  brim  and  intra- 
peritoneal. Careful  exploration  by  the  finger  of  the  roof  of  the  vagina 
will,  however,  in  all  probability,  lead  to  the  discovery  soniewhere  of  a, 
soft  spot,  through  which  the  needle  of  a  hypodermic  syringe  may  be 
carefully  passed  so  as  to  explore  the  tissues  beyond.  Thus,  the  diag- 
nosis will  usually  be  made  clear. 

The  hypodermic  syringe,  when  intelligently  used,  furnishes  us  a  per- 
fectly safe  means  for  the  exploration  of  pelvic  abscesses. 

Abscess  of  the  ovary  is  so  rare,  and  so  little  is  known  of  its  clinical 
history,  that  its  recognition  can  scarcely  be  expected. 

The  diagnosis  of  pyosalpinx  will  be  discussed  in  its  proper  place. 

Prognosis. — Pelvic  abscess  in  every  case  presents  a  situation  more 
or  less  grave.  Intraperitoneal  abscesses  are  usually  high  in  the  pelvis 
— indeed,  are  partly  abdominal  in  their  location ;  are  difficult  to  reach 
by  surgical  measures ;  and  even  after  their  contents  are  evacuated  a  sac 
may  remain  which,  unless  properly  di^ained,  will  continue  to  discharge 
pus  for  an  indefinite  period. 

Abscesses  of  the  cellular  tissue,  as  a  rule,  admit  of  a  more  favorable 


PELVIC  ABSCESS.  I'll 

proo"nosis.  I  I'sitiiati'd  low  tl<)\\ii,;is  in  the  iiircrinr  |»nriii)ii  ol' (hk;  of  tln' 
Itroad  liuMinciils,  or  il"  liM-atcd  in  tlu'  iliac  Ibssa  <»r  in  (lie  tissue  ol'  llic 
anterior  abdominal  wall,  a  cure  may  readily  be  obtained  by  incision  and 
<lrainai2;e. 

Ru|)tiu'e  of  tlie  abscess  uj)on  a  cutaneous  surface  or  into  the  vaiiina, 
with  tree  dischar<:;e,  is  favorable  to  speedy  recovery,  but  i-n|)ture  into  the 
bladder  or  rectum  is  not   desirable. 

Xonat  di'clarcd  that  when  the  abscess  "opens  simultaneously  into  the 
intestine  and  l)ladder,  death  is  alm(jst  inevitable."  Dr.  Thomas  ha.s 
emphasized  this  statement,  and  corroljoraled  it  by  the  results  of  a  ca.se 
under  his  care. 

Tkeatmi-:nt. — .Vlthough  sonu;  modern  gynecologi.sts,  like  Aran  and 
Becquerel,  and  very  recently  Prof.  Fritsch  of  Halle,  have  taught  that 
these  abscesses  should  not  be  interfered  Avith,  but  left  to  Nature — that  i.s, 
to  burst  into  the  vagiua,  the  bladder,  or  the  rectum — I  know  of  uo  good 
reason  why  they  should  not  be  treated,  like  abscesses  in  other  parts  of  the 
bodv,  in  accordance  with  the  general  principles  of  surgery. 

As  stated  by  Howard  Marsh,^  "  it  may  be  laid  down  as  a  general 
rule  that  pus  is  to  be  removed  as  soon  as  it  is  formed.  In  cases  of 
acute  abscesses  this  rule  may  be  considered  very  nearly  absolute.  We 
have  now  at  our  disposal  the  means  by  which  the  serious  complications 
that  were  formerly  met  with  as  the  result  of  putrefactive  changes  may 
be  avoided,  and  the  withdrawal  of  pus  has  a  very  beneficial  effect  in 
abating  the  severity  of  acute  inflammatory  processes." 

In  the  application  of  this  principle  to  any  given  case  our  conduct  will 
be  governed  by  the  situation  of  the  abscess,  by  its  character  whether 
acute  or  chronic,  and  by  the  condition  of  the  patient. 

As  has  been  clearly  emphasized  by  Sir  Jas.  Y.  Simpson  and  Prof. 
T.  Gaillard  Thomas,  no  rule  can  be  given  which  will  hold  good  in 
every  case  of  pelvic  absce&s.  The  safety  of  the  patient  may  in  one 
instance  demand  early  evacuation  of  the  pus ;  in  another  it  may  make 
delay  the  proper  course.  Grave  constitutional  symptoms,  high  fevers 
followed  by  heavy  sweats,  certainly  justify,  as  Bernutz  said,  an  almost 
dangerous  operation  for  the  relief  of  the  patient. 

In  most  instances  perhaps  reasonable  delay  is  the  better  course, 
because  the  ahscess  will  then  have  an  opportunity  to  become  ripe ;  the 
separate  accumulations  of  pus  Avhich  are  often  found  in  the  connective 
tissue  M'ill  then  have  coalesced,  and  a  thinner  wall  will  intervene 
between  the  pus  and  the  .surface  to  be  incised. 

It  is  true  that  while  we  wait  the  absce-ss  may  break  in  some  disagree- 
able direction  ;  but  it  is  also  true,  as  Aran  declared,  that  there  are  cases 
on  record  of  spontaneous  rupture  into  the  peritoneum  or  intestine  several 
days  after  artificial  puncture. 

'  Inlernat.  Encyclopcedia  of  Surg.,  vol.  ii.  p.  268. 


728  PERIUTERINE  INFLAMMATION. 

As  illustrating  the  danger  of  leaving  the  disease  to  Nature,  mention 
may  be  made  of  the  24  cases  of  pelvic  abscess  reported  by  McClintock  ^ 
which  were  thus  treated :  13  of  these  were  puer|)eral  and  11  were  non- 
puerperal. Four  of  the  patients  died  from  rupture  of  the  abscess  into 
the  bowel  and  an  uncontrollable  dysentery  which  followed ;  3  others 
died  of  rupture  into  the  peritoneum.     A  heavy  mortality ! 

Means  for  the  Evacuation  of  Pus. — 1.  Tlie  Knife. — The 
proper  instrument  for  the  evacuation  of  a  pelvic  abscess  is  the  knife. 
The  presence  of  pus  being  ascertained,  and  its  situation  being  favorable 
for  an  incision  through  the  roof  of  the  vagina,  the  patient  is  to  be  ether- 
ized and  placed  on  her  side.  Sims's  speculum  having  been  then  intro- 
duced, a  grooved  director  or  exploriug-needle  is  pushed  into  the  abscess- 
cavity  at  some  point  as  remote  as  possible  from  any  pulsating  vessels 
which  may  be  discovered.  As  soon  as  pus  appears  in  the  groove  a  tenot- 
omy-knife  is  to  be  passed  along  the  director,  and  the  opening  enlarged 
by  cutting  in  opposite  directions  until  it  is  capable  of  admitting  the 
index  finger. 

After  introducing  the  finger  into  the  cavity  any  partitions  which  may 
be  felt  are  to  be  broken  down.  A  full-sized  drainage-tube  should  then 
be  introduced,  and  secured  in  position  by  stitching  it  to  the  vaginal  wall. 
Through  this  tube  the  cavity  may  be  washed  out  every  day  or  oftener 
by  a  gentle  stream  of  pure  water,  or  the  water  may  be  made  stimulating 
and  disinfectant  by  a  solution  of  the  bichloride  of  mercury,  1 :  4000,  or 
of  Lugol's  iodine  somewhat  diluted. 

If  exploration  by  the  finger  shows  the  presence  within  the  abscess- 
cavity  of  those  fungoid  masses  which  Dr.  Byford  has  described,  they 
should  be  carefully  and  thoroughly  removed,  as  recommended  by  him, 
either  with  the  finger-nail  or  by  means  of  the  dull  curette.  This  measure 
he  found  beneficial  by  lessening  the  amount  of  discharge,  by  destroying 
the  offensive  odor  which  is  present,  and  by  hastening  the  closure  of  the 
cavity. 

The  abscesses  favorably  situated  for  this  plan  of  treatment  are  the 
suppurating  hsematoceles  and  other  piu-ulent  collections  in  Douglas's 
pouch,  the  parametric  abscesses  behind  the  uterus,  and  those  which  point 
at  the  base  of  the  broad  ligaments.  Iliac  and  abdominal-  wall  abscesses 
which  seek  an  opening  on  the  cutaneous  surface  are  to  be  approached  by 
careful  division  of  the  tissues  on  a  director,  as  in  the  operation  for  lap- 
arotomy. 

In  using  the  knife  for  making  incision  through  the  roof  of  the  vagina 
the  operator  should  bear  in  mind  the  dangers  of  wounding  large  venous 
plexuses  as  well  as  arterial  branches  which  ramify  through  the  con- 
nective tissue.  He  should  also  be  mindful  of  a  deplorable  accident 
which  has  sometimes  occurred,  and  which  can  hardly  be  foreseen  :  the 

1  Op.  cii. 


PELVIC  ABSCESS.  729 

uivtcr  iiKiv  Ik-  opened  and  a  iireter(t-\a<:iiial  fistula  re~ult.  'J'wo  >:i(h 
t-ases  have  come  iiiuler  the  oljservation  of  I  )r.  l^iiimet,  who  states  that 
ail  abscess  hetieath  the  folds  of  the  broad  li<rameiit  may  dia;^  the  iii-eter 
oi'  that  side  up  to  the  U'vel  of  the  va<;iiia  at  a  point  one  inch  alioveand 
the  same  distance  beliind  the  point  of  entrance  of  tlie  ureter  into  the 
l)ladder,  and  niav  attach  it  by  adhesions  to  the  vauiiia.  It  is  then  in  a 
position  to  be  injured  l)y  tiie  knife  in  o})ening-  the  al)scess.  In  one  of 
the  cases  referred  to  an  operation  for  relief  failed,  and  in  tlie  other  it 
Avas  successful  only  throui;h  the  great  skill  of  the  operator  and  the  Ibr- 
tunate  circunistance  that  the  urine  from  the  kidney  on  that  side  could 
be  turned  into  the  l)ladtler  through  the  tract  of  the  old  abscess. 

raipieli n's  cautery-knife  may  also  be  used  for  makin<j^  the  incision 
throuLih   the  roof  of  the  vagina  instead  of  the   ordinary  knife. 

Many  pelvic  abscesses  are  so  situated  that  the  plan  of  treatment  just 
described  is  wholly  inadmissible.  Quite  often  the  pus-cavity  is  high  in 
tlie  pelvis,  the  vaginal  roof  is  thickened  by  false  membranes,  and  the 
j)elvic  organs  are  drawn  so  closely  together  by  an  adhesive  i)eritonitis 
that  the  abscess  cannot  be  approached  through  the  vagina  at  all.  For 
this  class  of  cases  the  proper  means  of  relief  is  to  be  found  in  the 
operation  of  abdominal  section,  as  proposed  and  successfully  practised 
by  Mr.  Lawson  Tait.  This  method  oifers  a  means  of  cure  to  a  large 
number  of  cases  which  cannot  be  successfully  treated  in  any  other  way, 
and  which  have  hitherto  resulted  in  death  or  hopeless  invalidism. 

Alluding  to  the  history  of  chronic  pelvic  abscess  as  given  Ijv  Dr. 
West,  Mr.  Tait  says  :  ^  "In  my  own  practice  such  disappointing  cases 
have  occurred  with  but  too  great  frequency,  and  though  I  have  had 
some  successes  by  the  employment  of  such  means  as  the  elastic  ligature 
and  coimter-opening  in  the  vagina,  yet  the  progress  toward  recovery 
has  been  so  protracted  as  to  contrast  favorably  only  with  those  cases  in 
which  there  was  no  recovery  at  all.  I  have  been  therefore  continually 
on  the  outlook  for  some  means  of  dealing  with  such  cases  Avhich  would 
bring  them  as  satisfactorily  Avithin  our  means  of  treatment  as  are  col- 
lections of  matter  in  most  other  parts  of  the  body.  This  has  been  fur- 
nished by  the  wide,  free,  and  successful  application  of  abdominal  sec- 
tion for  the  trciitment  of  pelvic  and  al)dominal  tumors,  and  I  have  now 
to  lay  before  the  society  six  cases,  which  include  the  whole  of  my  expe- 
rience in  this  novel  proceeding,  and  in  which  success  has  1)cen  obtained 
far  surpassing  anything  I  have  yet  seen  or  heard  of." 

Mr.  Tait  oifers  this  as  a  means  of  treatment  for  all  purulent  accumu- 
lations in  the  pelvis  which  cannot  be  safely  opened  from  below,  and  he 
recommends  that  in  case  of  doubt  an  exploratory  abdominal  section  be 
first  made.  The  cases  which  he  has  successfully  treated  thus  are  pyo- 
salpinx,  acute  purulent  peritonitis  from  rupture  of  distended  tubes, 

1  Diseases  of  the  Oraries  4th  ed.,  1SS3,  p.  346. 


730  PERIUTERINE  INFLAMMATION. 

abscess  of  the  ovaiy,  abscesses  in  the  ujDper  part  of  the  broad  ligament, 
and  suppurating  hsematoceles.  In  his  fifth  case  the  cavity  of  the  abscess 
was  formed  bj  the  lifting  up  of  the  posterior  layer  of  the  left  broad 
ligament.  The  rectum  was  carried  up  in  front  of  this,  together  with 
the  large  vessels  of  both  sides,  as  high  as  the  bifurcation  of  the  aorta, 
whilst  anteriorly  the  peritoneum  dipped  to  such  an  unusual  depth  that 
had  he  tapped  through  the  vagina  the  trocar  would  have  gone  through 
the  peritoneal  cavity  to  reach  the  abscess. 

After  the  abdominal  incision  is  made  and  the  purulent  accumulation 
brought  into  view,  it  is  aspirated ;  then  a  free  incision  is  made  into  the 
abscess  Avail,  and  its  edges  are  carefully  stitched  to  the  edges  of  the 
abdominal  wound.  A  drainage-tube  of  glass  or  rubber  is  then  inserted, 
and  the  cavity  is  daily  washed  Avith  plain  water. 

In  some  cases  the  abscess  wall  is  adherent  to  the  abdominal  wall  in 
front.  In  such  the  treatment  is  more  simple — evacuation  of  its  con- 
tents and  drainage.  In  other  cases  the  accumulation  of  pus  is  small 
and  is  deep  down  in  the  pelvis.  Here  the  work  inside  the  abdomen 
will  consist  in  separating  the  attachments  of  adherent  viscera  and  in 
ligating  and  removing  the  diseased  appendages.  While  doing  this  the 
abscess-cavity  may  be  ruptured  and  its  contents  discharged  into  the 
peritoneum.  The  pus  should  then  be  carefully  taken  up  by  spong- 
ing, and  the  pelvis  washed  scrupulously  clean  with  warm  water  and 
drained. 

Mr.  Tait  has  now  operated  in  this  way  a  great  number  of  times,  and 
his  example  has  been  followed  by  other  surgeons  with  varying  success. 
He  says  :  ^  "  My  general  conclusion  from  these  cases  is  that  the  opening 
of  such  abscesses  by  abdominal  section  is  neither  a  difficult  nor  a  dan- 
gerous operation ;  that  recovery  is  made  in  this  way  more  certain  and 
rapid  than  in  any  other ;  and  that  in  future  I  shall  always  advise  an 
exploratory  incision  where  I  am  satisfied  there  is  an  abscess  which  can- 
not be  reached  nor  emptied  satisfactorily  from  below." 

Occasionally  the  disease  we  are  considering  assumes  a  form  which  in 
all  its  clinical  aspects  very  closely  resembles  the  last  stage  of  pulmonary 
consumption.  There  is  great  emaciation,  profound  anaemia,  and  drop- 
sical swelling  of  the  lower  extremities.  Along  with  a  rapid  pulse  and 
fever  of  a  remittent  type  and  profuse  sweating,  there  is  constant  pain, 
which  necessitates  the  daily  and  nightly  use  of  opium.  The  pelvic 
roof  is  hard  and  resistant,  and  in  places  greatly  thickened.  Though 
no  distinct  tumor  may  have  formed,  the  symptoms  indicate  that  sup- 
puration has  long  since  occurred,  and  it  is  not  difficult  to  find  one  or 
more  collections  of  pus.  This  may  be  evacuated  by  the  trocar  or  aspi- 
rator, but  not  even  temporary  improvement  will  follow,  because  the 
relief  is  only  partial,  and  the  entire  cellular  and  peritoneal  tissues  of 

^  Op.  eit.,  p.  351. 


J'j:lvi('  AJiSCESS.  7:U 

tilt'  jK'lvis  ai'c  iiiv(»l\c(l  in  iiill;iiniii;iliHii.  J-'or  siu\\  cases  alxluiiiinal 
section  and  <li'aiiiai;c  may  lie  j)r(»|)(»s('<l  as  a  la>l  I'tsort. 

2.  T/w  ^[Kjtit'dtor. — 'riiis  lu'aiitil'iil  coiitrivaiicc  lias  hccii  recoiniueiKlt'il 
by  some  surucons  as  a  safe  and  certain  iiicaiis  for  llic  ciii-c  of  alisccsses 
wliicli  are  si-atcd  \\\<j:\\  ii))  in  the  pelvis  and  so  suri'oiinded  that  tlie\- 
cannot   he  readilv  rt-ached   throniili   the  vai;inal   rool"  hy  the  knile. 

J)r.  (i.  II.  Lyman'  lias  pi-esentcd  an  interestini;- contril)nti<»n  to  this 
sulyeet  in  the  sha])e  oi"  a  rc|)ort  of  41  cases  of  pelvic  ahscess  treated  hy 
himself  and  collea<2;iies  in  the  IJoston  City  Hospital.  Jn  some  of  these 
eases  the  ahscess  was  evacnated  by  a  troear,  th(  camila  of  which  wa.s 
left  in  as  a  <lrainai;-e-tnbe,  or  else  some  other  Ji  ans  of  di-aina^e  was 
used;  but  17  casc-s  were  treated  by  aspiration  alon*  — that  is,  by  sinij>Iy 
emptying  the  cavity  with  the  as})irator,  without  wa  hing  or  injecting  it 
in  anyway.  Of  this  nnnd)er,  10  were  reported  cured;  4  were  not 
benefited;  1  was  improved  only;  2  were  injured.  In  4  eases  serum, 
clear  or  bloody,  was  removed  by  the  as])irator.  In  3  of  these  uo 
improvement  ibl lowed,  while  the  fourtli  was  cured. 

In  regard  to  these  cases  I  woidd  remark  that  the  results  reported  are 
probably  too  favorable,  for  the  following  reasons :  It  is  almost  impos- 
sible to  learn  the  subsequent  history  of  this  class  of  patients.  One  of 
these  cases,  as  shown  by  the  report,  was  discharged  from  the  hospital 
while  remnants  of  exudation  were  still  recognized  in  the  pelvis.  Some 
remained  only  a  few  days  after  the  operation,  one  being  discharged  five 
days  after  aspiration,  another  thirteen,  another  fourteen  davs.  The 
report  cannot,  therefore,  be  considered  conclusive  in  regard  to  the 
question  of  cure. 

A  knowledge  of  the  pathology  of  absce&s,  of  the  structure  of  the 
walls  of  chronic  abscesses,  and  of  the  almost  invariable  presence  of 
diseased  uterine  appendages  in  peritoneal  collections,  must  convince  us 
that  the  cure  of  the  disease  is  rarely  to  be  obtained  by  aspiration.  "SMien 
the  purulent  accumulation  has  been  withdrawn  by  the  aspirator,  clots 
of  blood,  sloughs  of  connective  tissue,  and  shreds  of  lymph  too  large 
to  pass  through  the  canula  are  usually  left  behind,  either  to  continue 
the  suppurative  process,  or  else,  in  all  probability,  to  furnish  the  excit- 
ing cause  for  those  "  residual  abscesses  "  -which  Mr.  Paget  -  has  shown 
are  often  "formed  in  or  about  the  residues  of  former  inflammations. 
Most  of  them  are  formed  when  pus  produced  long  j^reviously  has  been 
wholly  or  in  part  retained  and  become  dry  or  in  some  form  obsolete." 

In  one  of  my  cases  treated  by  aspiration  there  was,  in  connection 
with  a  large  serous  accumulation  in  Douglas's  pouch,  a  collection  of 
pus  in  the  cellular  tissue  of  the  pelvis  and  the  anterior  abdominal  Avail. 
The  patient  did  well  for  many  months,  but  a  year  afterward  a  large 
accumulation  suddenly  formed  in  the  pelvis  without  appreciable  cause 

'  Trans.  Am.  Gyn.  Soc,  vol.  vi.  -  Clinical  Lectures  and  Essays,  2d  ed.,  p.  309. 


732  PERIUTERINE  INFLAMMATION. 

aud  without  complaint  of  pelvic  symptoms,  with  all  the  signs  of  septi- 
csemia,  rapid  pulse,  high  temperature,  and  delirium,  and  terminated 
fatally  in  a  few  days.  My  conclusion  w^as  that  this  inflammation  had 
its  origin  in  a  residual  abscess.  Just  before  death  a  quart  of  fluid  w^as- 
withdrawn  by  aspiration,  the  first  and  far  the  greater  portion  of  which 
was  deep  straw-colored  serum ;  the  last,  thick,  bad-smelling  pus. 

My  own  experience  with  aspiration  in  the  treatment  of  pelvic  abscess- 
has  been  far  from  satisfactory  as  a  curative  measure,  and  in  several 
cases,  though  large  amounts  of  pus  were  withdrawn,  there  has  not  fol- 
lowed even  temporary  relief. 

I  believe  that  the  use  of  the  aspirator  should  be  restricted  almost 
entu-ely  to  purposes  of  diagnosis  and  to  the  evacuation  of  those  chronic 
serous  effusions  which  persist  in  spite  of  all  other  treatment.  Safe  as 
aspiration  may  seem  when  properly  performed,  it  is  not  devoid  of 
danger.  If  the  needle  be  thrust  into  a  hsematocele  by  mistake, 
instead  of  an  abscess,  violent  inflammation  and  death  may  ensue,  as 
in  Case  A^I.  of  Dr.  Lyman's  report ;  and  Dr.  Thomas  quotes  a  case 
from  the  Boston  Medical  Journal  in  which  air  entered  the  veins  dur- 
ing aspiratiou  and  the  patient  died  in  ten  minutes. 

Whenever  resorted  to,  aspiration  should  be  practised  with  strict  anti- 
septic precautions. 

Treatment  of  SixrsES. — It  is  not  unfrequently  the  case,  when  the 
patient  first  comes  under  observation,  that  the  abscess  has  already  dis- 
charged itself  through  one  or  several  openings,  and  as  many  separate 
sinuses  remain.  If  there  be  several  openings,  it  is  a  matter  of  import- 
ance to  ascertain  whether  they  all  communicate  with  each  other  and 
acknowledge  a  common  source.  To  pass  a  probe  from  one  of  these 
openings — on  the  cutaneous  surface,  for  example — through  a  circuitous 
route,  and  make  it  emerge  at  another,  cannot  often  be  done.  But  by 
injecting  iodine  diluted,  or  some  other  colored  fluid,  into  one  of  the 
openings,  it  T^^ll  appear  at  all  the  others  if  a  communication  exists. 

Various  expedients  have  been  devised  for  the  closure  of  these  sinuses. 
The  principle  which  underlies  them  all  was  proposed  by  Sir  James  Y. 
Simpson  in  his  Clinical  Lectures  on  the  Diseases  of  Women,  and  his 
remarks  on  the  treatment  of  pelvic  abscess  are  well  worth  a  careful 
study  now. 

The  vagina  is  the  most  desirable  channel  for  the  evacuation  of  a 
pelvic  abscess.  Simpson  proposed,  when  the  abscess  has  discharged 
itself  at  some  other  point  and  a  sinus  remains,  that  a  counter-opening 
should  be  made  in  the  vagina.  His  plan  was  to  pass  a  large  probe  or 
sound  through  some  opening  above  the  pelvic  brim  down  into  the  pel- 
vis, until  its  point  was  felt  by  the  side  of  the  womb  in  the  upper  part 
of  the  vagina.  Then,  cutting  upon  this  as  a  guide  at  the  most  depend- 
ent point  of  the  abscess-cavity,  a  counter-opening  was  made.    The  open- 


PF.IAIC  AflSCESS.  7:V.) 

inu"  ill  tlic  va!i;iiia  may  (lien  \h'  ciilarticd  l)y  tlic  kiiil'c  m-  a  dilator,  so  as 
to  admit  one  or  two  liiiucrs  loi-  |)iirj)oscs  of  cxploratiftii. 

1 1"  tlu'  abscess  should  have  opened  into  llie  bladder  or  i-eelimi,  in-tead 
ot"  upon  the  entaneons  surface,  tiie  pi'(i|)ei'  means  slmuld  !)<•  adnpicd  for 
Hudiui;"  the  openinj;-  into  these  cavities  and  ])assini;-  throuiih  it  th(;  lar<^e 
])rol)e  until  the  locality  ibi-  the;  vaginal  eouutei--opening  is  made  clear. 
If  this  is  im|)ractical)le,  we  may,  as  Dr.  IJyfbrd  suggests,  aspirate  the 
vaginal  wall  with  a  view  of  finding  the  old  abscess-cavity,  and  then  cut 
with  the  bistoury  upon  the  asj)irator  as  a  guide. 

A  drainage-tube  of  glass  or  rubber  being  introduced,  the  daily  wash- 
ing out  of  the  cavity  with  warm  water,  made  stimulating  and  antiseptic 
with  iodine  or  Jjal)ari-a(pie's  solution  of  chlorinated  soda,  will  in  some 
■cases  bring  about  a  cure. 

In  many  cases  no  })lace  can  be  found  for  making  this  counter-open- 
ing. If  the  patient's  condition  is  not  bad,  and  the  sinuses  are  small 
and  discharge  but  little  pus,  their  closure  may  be  accomplished  now 
and  then  by  the  application  to  their  walls  of  a  strong  tincture  of  iodine. 
In  other  cases,  where  the  patient's  health  is  seriously  impaired  and  this 
])lan  proves  ineffectual,  resort  to  abdominal  section,  removal  of  diseased 
<ip])endages,  and  drainage  will  become  necessarv. 

Finally,  during  the  surgical  treatment  of  these  conditions  attention 
must  be  paid  to  the  general  health,  and  we  must  invoke  the  aid  of 
tonics  and  stimulants,  of  fresh  air  and  sunshine.  These  are  the  general 
principles  involved  in  the  treatment  of  pelvic  abscess.  While  many 
cases  will  be  thus  successfully  treated,  others  will  tax  to  the  utmost  all 
the  resources  of  surgery,  and  some  will  prove  entirely  beyond  the  reach 
of  our  art. 


PELVIC   HyEMATOCELE  AND  HJiMATOMA. 

By  ELY  VAN    DK  WARKEK,   .M.  1)., 

Syracuse,  N.  Y. 


XoMENCT.ATiTRE. — Tlic  term  "  hfcniatocele "  is  based  by  Bernutz, 
the  author  of  the  word,  upon  the  hypothetical  resembhince  of  the 
pentoueal  cul-de-sac  of  the  female  pelvis  to  the  tunica  vaginalis  of 
the  male,  and  is  used  to  define  a  collection  of  blood  in  the  pelvic 
excavation  within  the  peritoneiuii.  Bernutz  limited  the  term  to 
haematic  collections  due  to  hemorrhage  from  the  internal  genitalia, 

Most  authors  exclude  pelvic  hemorrhage  caused  by  rupture  of  extra- 
uterine gestation-sacs,  of  aneurismal  tumors,  ovarian  cysts,  or  blood- 
eifusions  due  to  accident  or  injury.  Some  exclusion  is  necessary,  as 
the  term  hematocele  does  not  define  a  disease,  but  only  a  result  that 
may  be  the  outcome  of  various  conditions.  In  order  to  give  the  term 
clinical  significance,  hnematoceles  of  pelvic  origin,  in  the  absence  of  a 
better  word,  must  be  arbitrarily  limited  to  certain  well-defined  sources 
of  hemorrhage.  With  this  view  the  limits  imposed  upon  the  term  by 
Nelaton  are  adopted  in  this  article.  Nelaton  restricted  its  meaning  to 
a  definite  pelvic  location  by  the  word  retro-uterine.  As  the  haematic 
collection  is  not  always  located  in  the  sac  of  Douglas,  the  term  pelvic 
haematocele,  first  used  by  McClintock,  is  by  far  the  better  one,  and  is 
now  in  general  use. 

To  be  a  true  pelvic  hematocele,  to  carry  out  the  hypothetical  anal- 
ogy between  pelvic  peritoneal  duplicatures  and  the  tunica  vaginalis,  the 
blood  must  become  encysted  within  the  pelvis.  Although  a  true  cyst 
never  enchases  the  effused  blood,  as  good  an  authority  as  McClintock 
divides  pelvic  hematocele  into  two  groups — enci/stcd  and  non-enci/sted ; 
which  division  has  gained  currency  as  defining  the  incarceration  of  the 
blood-mass  by  adhesions  of  contiguous  peritoneal  surfaces. 

Some  of  the  terms  qualifying  pelvic  hematocele  have  led  to  confu- 
sion, which  has  resulted  in  confounding  two  distinct  pelvic  conditions. 
Nelaton  brought  into  use  the  terms  ciiTumKfcrlnc  and  periuterine  Jievma- 
tocele,  which  are  now  frequently  employed  to  designate  a  pelvic  hema- 
toma. As  it  is  important  to  make  a  careful  distinction  between  hema- 
tocele and  hematoma,  the  terms  ought  to  be  abandoned.     Gallard,  who 

v:^5 


736  PELVIC  HEMATOCELE  AND  HMMATOMA. 

made  frequent  use  of  the  terms,  employed  them  without  reference  to 
the  peritoneal  relations  of  the  eifused  blood.  If  we  have  made  no 
other  advance  since  Gallard  wrote  (1857),  we  ought  to  have  gained 
precision  in  the  use  of  terms. 

While  McClintock  divided  hsematoceles  according  to  the  condition 
of  the  effusion,  others  have  based  the  classification  upon  either  the 
source  of  the  hemorrhage  or  its  anatomical  relations.  Genouville 
makes  two  groups — the  catamenial  and  the  accidental;  but  here,  in 
order  to  group  a  case,  it  is  necessary  to  define  the  source  of  hemor- 
rhage, which  is  in  many  cases  impossible.  Barnes  makes  an  elaborate 
classification  of  two  groups  and  five  sub-groups,  and  writes  of  it  as 
though  it  was  a  material  addition  to  our  knowledge  of  the  subject. 
Barnes  has,  however,  added  a  very  expressive  word — cataclysmic — to 
describe  large  and  sudden  effusions  attended  by  alarming  or  fatal  col- 
lapse. Excluding  rupture  of  the  parturient  uterus  and  of  tubal  gesta- 
tion-cysts, which  Barnes  includes  in  this  sub-group,  hemorrhage  of  a 
cataclysmic  character  belongs  to  a  diseased  ovary,  rupture  of  the  pam- 
piniform plexus,  or  of  the  subovarian  vessels. 

Great  confusion  obscures  the  relations  of  hsematocele  to  hsematoma, 
and,  although  the  terms  express  two  very  different  classes  of  pelvic 
haematic  tumors,  the  words  have  been  used  by  good  authors  as  synon- 
ymous. Such  terms  as  hsematocele  ligamenti  lati  (Bandl) — and  which, 
according  to  Nelaton,  are  small  blood-effusions  in  the  broad  ligaments 
which  are  very  common  and  mild  in  their  course — Huguier's  pseudo- 
hsematocele,  and  Gallard's  circumuterine  and  periuterine  hsematocele, 
have  added  useless  confusion  to  the  nomenclature  of  a  difficult  subject. 
If  we  add  to  this  confusion  of  terms  the  fact  that  writers  who  have 
shaped  opinion  upon  this  phase  of  pelvic  pathology  have  denied  the 
existence  of  extraperitoneal  effusions  of  blood  in  the  pelvis,  except  in 
connection  with  gestation  and  the  puerperal  state  (Bernutz),  and  when, 
granting  the  possibility  of  such  effusion,  we  have  applied  the  terra 
thrombus  (Meadows),  we  are  able  to  form  an  idea  of  the  status  of 
hsematoma  as  a  distinct  symptom  of  a  pelvic  condition.  Notwithstand- 
ing the  authority  of  Bernutz  and  Meadows,  the  term  thrombus  ought 
never  to  be  applied  to  an  extraperitoneal  effusion  of  blood,  but  restrict- 
ed in  its  gynecic  sense  to  blood-exudations  of  the  external  genitalia. 
When  upon  the  subject  of  hsematoma  the  term  will  be  confined  to 
this  condition. 

By  the  term  hsematoma  we  describe  an  effusion  of  blood  between  the 
folds  of  the  broad  ligaments  or  in  the  connective  tissue  surrounding  the 
uterus  and  vagina,  and  which  is  now  clearly  recognized  and  differenti- 
ated from  hsematocele.  Hsematoma  is  without  the  peritoneum;  hsema- 
tocele is  within  the  peritoneum ;  and  upon  this  simple  declaration  this 
article  will  be  based. 


ILKMATOLKLl-:.  T.'J 

H-EMATOCELE. 

HlSToiJ^'. —  PoMcct  states  tli;ii  in  ilic  works  of  I  li|>|HMiaii>  jMKic 
luvinatocclo  is  ck-arly  (Icscrilx'tl,  Iml  IVoiii  that  ])critMl  ddwii  to  l(j71 
IK)  ivti'i-eiice  is  found  to  tlie  disease  until  that  year,  wlien  Knv.-eh  ^A' 
AiiLsterdain  aeeunitely  deseril)e<I  the  menstrual  variety  <.l"  lut'iuatoeele, 
proviufT  the  escape  of  blood  outward  throuiih  the  l''allo|»ian  tuhes  into 
the  peritoneal  cavity,  anticipating  liernutz  one  hundred  and  seventv- 
four  yeai-s.  In  Hufeland's  Journal  (1818)  another  case  of  this  variety 
is  described.  P.  Franck  in  1823  added  other  facts  to  our  kno\vled<re 
of  the  subject,  Init  to  Bourdon,  a  follower  of  Kecaniier,  belongs  the 
honor  of  Hist  describing  the  physical  signs  of  liaeniatocele,  demonstrat- 
ing its  en(ysted  character  and  j)laci])g  the  lesion  in  the  periuterine  cel- 
lular tissue,  liernutz  published  his  first  memoir  upon  the  subject  in 
1848,  the  beginning  of  a  series  of  memorable  papers.  Vigu5s  in  1850 
based  his  (observations  upon  seven  cuses,  descriljed  the  effused  blood  its 
extraj)eritoneal,  and  explained  the  source  of  the  hemorrhage  as  ovarian. 
Xelaton  in  LSol  fii-st  gave  the-disease  a  status  in  literature,  describing 
the  tumor,  its  signs,  and  treatment,  from  which,  in  its  essential  features, 
there  has  been  no  departure  to  this  day.  In  the  French  Academy  in 
the  same  year  a  memorable  discussion  took  place  upon  a  paper  by 
Monod  descrii)ing  a  retro-uterine  hsematocele.  Xelaton,  Robert,  Hu- 
guier,  Denouviliers,  Lenoir,  took  part  in  the  discussion.  Kobert 
established  the  declaration  of  the  pelvic  regions  involved  in  tlie  effu- 
sions, the  most  important  of  which  "was  the  broad  ligament,  while 
Huguier  enunciated  his  anatomical  classification  of  intra-  and  extra- 
peritoneal "which  endures  to  this  day.  Here,  also,  the  treatment  by 
puncture  was  first  proposed,  and  Mas  twice  made  by  Denouviliers.  In 
the  thesis  of  Prost  in  1854  the  distinction  of  extra-  and  intraperitoneal 
was  firmly  settled.  He  fii-st  gave  the  physical  signs  of  depression  of 
the  uterus  in  intra-  and  its  elevation  in  extraperitoneal  blood-effusions. 
To  English  literatiu-e  Tilt  has  given  the  most  elaborate  contributions 
(1853),  but  the  condensed,  graphic  narrative  of  McClintock  has  had 
more  influence  upon  the  coui'se  of  opinion.  In  1855,  Langier  dem- 
onstrated the  ovary  as  the  source  of  blood-escape  Mith  its  histological 
alterations.  In  the  same  year  Gallard  rendered  a  valuable  service  by 
pas-ing  in  review  the  literature  of  the  whole  subject  to  liis  date,  and 
reduced  to  order  the  fragmentary  mass  of  facts.  In  this  year  also 
Pencil  (de  Toulouse)  made  a  material  contribution  by  demonsti-ating 
the  several  sources  of  hemorrhage,  as  lesions  of  the  tul)es,  the  ovaries, 
and  the  ovarian  venous  plexus.  In  1858,  Voisin  published  the  most 
complete  monograph  yet  offered  upon  the  subject,  and  may  be  said  to 
have  concluded  the  period,  one  of  the  most  brilliant  in  French  medical 
history. 

Vol.  I.— 47 


738  PELVIC  H^EMATOCELE  AND  HJSMATOMA. 

In  Germany  the  period  of  literary  activity  coincided  in  date  with 
that  in  France.  The  first  cases  of  note  were  described  by  Herzfelder 
(1856),  and  by  Crede  (1857),  Heyer,  Breslau,  Ukich,  Braun  (1860), 
Krieger,  and  Ott  (1863).  In  the  works  of  Schroeder,  Beigel  and 
Olshausen,  and  Klebs  valuable  references  may  be  found.  The  views 
of  Virchow,  that  the  hemorrhage  is  due  to  the  rupture  of  neo-mem- 
branes  within  the  pelvis,  have  gained  ascendency  in  Germany.  Many 
of  the  above  notable  papers  are  found  in  the  files  of  the  Monatschrift 
fur  Geburtskunde,  so  rich  in  gynecic  literature  during  the  formative 
period  in  Germany. 

In  England,  besides  the  important  contributions  of  Tilt  and  Mc- 
Clintock,  we  have  those  of  Madge,  Snow  Beck,  Meadows,  Duncan, 
Simpson,  and  in  the  works  of  Hewitt,  Bennet,  Churchill,  Tait,  and 
others. 

In  America,  although  the  subject  has  been  well  understood,  but  little 
original  work  has  been  done.  Bedford  in  1855  was  among  the  first 
to  make  a  material  contribution;  Byrne  followed  in  1862  with  a  very 
valuable  monograph ;  C.  C.  Lee  and  Harrison  are  also  later  authors  of 
excellent  papers ;  while  the  more  recent  American  textbooks — notably 
those  of  Thomas  and  Emmet — have  given  liberal  space  to  the  subject. 
From  these  beginnings  the  literature  of  hsematocele  and  hsematoma  has 
assumed  grand  jDroportions.  An  examination  of  the  material  upon 
the  subject  in  the  library  of  the  Surgeon-General's  Office  at  Washing- 
ton, as  enumerated  in  the  Index  Catalogue,  shows  four  hundred  and 
fifty-five  titles. 

Causes. — Hsematocele  and  heematoma  are,  for  the  purpose  of  de- 
scription, regarded  as  diseased  entities.  They  are,  however,  merely 
symptoms,  and  as  such  must  be  studied  in  their  causative  relations. 

There  have  been  marked  and  intimate  relations  traced  between  hsema- 
tocele and  ovarian  function,  and  in  consequence  age  has  a  direct  bearing 
upon  the  liability.  Voisin  shows  that  the  ages  between  twenty-five  and 
thirty-six  years  define  the  period  of  greatest  frequency.  The  ratios  of 
those  attacked  at  twenty-one  years  and  at  forty  correspond.  Schroeder's 
observations,  based  upon  forty -three  cases,  confirm  those  of  Voisin. 

Concerning  the  relative  frequency  of  hsematocele  authors  differ  so 
widely  that  no  conclusion  can  be  reached.     Thus — 

Hugenberger         reports    2  in  3801  cases. 
Seyfort  "       66  "   1272     " 

Olshansen  "       34  "  1145     " 

The  latter,  again,        "       29  "     769     " 
Bandl  "         5  "  1500     " 

Scanzoni  in  twenty-eight  years'  practice  met  with  hsematocele  only  eight 
times.     Barnes  in  his  paper  read  before  the  Obstetrical  Society  of  Lon- 


Il.KMA  TiKELE.  I'.V.) 

(loll  astuiiislii'tl  his  aiidicncc  l)y  the  rri'(iii<'ri<v  with  \\hi<h  he  met  with 
the  accident,  and  ii|)itn  this  assertion  ahuie  Mea(h)\\s  (»[)enly  attacked 
the  cnrrectness  of  his  diagnosis. 

This  wide  divergence  in  experieiiee  may  he  e.\|»Iained  hy  the  state- 
ment that  ()l)sei'vcrs  wlio  hase  their  ratios  npon  hospital  records  meet 
wilh  ha'matoccic  los  ot'tcii  than  those  who  are  enjia^ed  in  consultation- 
work.  1  hematocele  is  nsnaily  \cry  sndch-n  and  severe  in  its  onn-t,  and 
is  moi'c  often  a  domiciHary  than  a  hospital  case. 

The  rcproihiclive  ai;c  at  its  period  of  greatest  activity  bcni}^  the  period 
most  proiii'  to  attack,  snl)stantiates  the  theory  that  many  writers  adhere 
to,  that  the  ovaries  and  their  essential  accessories,  the  tnhes,  are  the  parts 
commonlv  conct'iMicd  in  the  morl»id  conditions  that  I'csnk  in  luematwele. 
Voisin  oixserves  that  the  i;i-eater  mnnher  of  htematoeeles  occur  near  or 
at  the  end  of  the  menstrual  period,  and  when  the  hicmatic  accident 
take.s  place  menstruation  ceases  or  is  lessened  in  amount.  This 
mav  he  true  as  a  clinical  observation,  but  is  not  made  clear  by  Bandl's 
explanation  that  the  freipient  develo|)ment  of  hiematoeele  during  men- 
struation is  due  to  the  hiiili  blood-pressure  in  the  ovarian  vessels,  from 
which,  having  been  weakened  by  morbid  changes,  they  give  way.  The 
treneral  hiirh-tension  condition  of  the  circulation  that  characterizes  the 
menstrual  process  is  greater  at  the  beginning  of  the  function,  and  the 
inference  is  clear  that  this  ought  to  be  the  period  of  greater  liability. 
Tilt  substantiates  this  idea,  as  ha?matocele  presents  itself  in  two  opposite 
conditions — namely,  in  the  total  absence  of  menstiniation,  and  when  it 
is  morbidly  j)rofuse  (menorrhagia).  In  the  absence  of  the  discharge 
the  hemorrhagic  loss  attending  the  formation  of  the  hsematocele  would 
sup})lant  the  menstrual  discharge. 

Bcrmitz  and  Tilt  are  the  most  determined  advocates  of  the  menstrual 
origin  of  haematocele.  Tilt  concludes  his  book  on  Uterine  and  Ovarian 
Inffammation  by  the  rather  dogmatic  statement :  "  The  occurrence  of 
hrematocele  is  one  of  the  penalties  of  allowing  the  menstrual  functitm 
to  be  habitually  morbid."  Such  positive  statements  must  not  lead  to 
the  conclusion  that  haematocele  is  ever  due  to  a  functional  derangement 
of  the  ovaries.  Such  has  been  the  theory  advanced,  but  there  is  no  evi- 
dence to  prove  a  vicarious  origin,  in  the  absence  of  organic  lesion,  of 
the  pelvic  accumulation.  Tyler  Smith  takes  this  view,  and  supports  it 
by  the  clinical  fact  that  the  ha^natocele  is  frequently  augmented  l)v 
renewal  of  the  hemorrhage  at  each  menstrual  period  ;  but,  while  the 
fact  must  be  admitted,  its  explanation  is  not  a  logical  one.  Bernutz's 
theory  is  a  better  one,  that  it  is  a  morbid  excretion  from  the  tube  and 
uterus,  but  only  a  portion  of  the  discharge  is  so  etfused,  as  in  this 
variety'  (metrorrhagic  hsematocele)  there  is  always  an  external  discharge 
of  blood  at  the  same  time. 

Bernutz  makes  four  clinical  groups.    The  tirst  is  comprised  of  liama- 


740  PELVIC  HEMATOCELE  AND  HEMATOMA. 

tocele  occurring  in  eruptive  fevers  and  febrile  conditions  (purpura,  black 
jaundice) ;  second,  all  those  cases  that  attend  flooding  after  childbirth  or 
abortion ;  third,  hsematoceles  of  metrorrhagic  character  symptomatic  of 
pelvic  peritonitis :  this  last  is  purely  a  theoretical  group,  difficult  if  not 
impossible  to  differentiate ;  the  fourth  group  is  characterized  by  some 
cachexia  or  observed  in  women  subject  to  floodings. 

Courty  states  that  four  sources  of  hemorrhage  have  been  demonstrated 
by  autopsy.  They  are  as  follows,  in  the  order  of  frequency :  Apoplectic 
hemorrhage  from  the  ovaries ;  hemorrhagic  pachyperitonitis ;  rupture 
of  one  of  the  vessels  of  the  ovarian  plexus ;  and,  lastly,  tubal  hemor- 
rhage (rupture).  The  latter  source  has  given  origin  to  the  theory 
expressed  by  Lee,  Poncet,  Raciborski,  and  others — and  to  the  truth  of 
which  a  few  demonstrations  attest — that  the  inner  surface  of  the  tubes 
will  secrete  blood  at  a  menstrual  period  like  the  endometrium.  If  the 
uterine  extremity  of  the  tube  is  closed,  the  blood  will  escape  at  the  fim- 
brise,  and  thus  cause  a  retro-uterine  hsematocele.  If  the  abdominal 
opening  of  the  tube  is  also  closed,  a  hematosalpinx  is  formed.  In 
case  such  a  tube  is  ruptured,  hsematoma,  rather  than  hsematocele,  is 
formed.  Barnes  makes  four  sub-groups :  1,  early  Fallopian  gestation 
and  escape  of  ovum  into  the  peritoneal  cavity ;  2,  mechanical  impedi- 
ment to  the  escape  of  menstrual  blood ;  3,  interrupted  or  disturbed  men- 
struation from  (a)  cold,  over-exertion,  (6)  emotion,  (c)  excessive  sexual 
intercourse ;  4,  hemorrhagic  tendency  induced  by  disease,  among  which 
may  be  mentioned  jaundice  in  pregnancy  and  excited  by  strong  emotion 
or  physical  shock. 

Bernutz  says  that  a  large  and  important  class  of  hsematoceles  is  the 
result  of  a  defect  in  the  relation  of  the  tube  to  the  ovary.  If  any  such 
source  exists,  it  must  be  the  result  of  pelvic  peritonitis  causing  adhesions, 
with  distortion  of  either  the  tube  or  ovary  in  their  relation  to  each  other. 
But  there  is  no  post-mortem  evidence  of  the  fact.  Madge  gives  import- 
ance to  ovarian  apoplexy  as  a  cause  of  hsematocele.  A  small  blood- 
vessel gives  way  in  the  ovarian  capsule,  and  a  blood-extravasation 
occurs,  with  a  gradual  augmentation  m(mth  by  month  until  the  ovarian 
stroma  is  ulcerated  (ulceration  of  ovary).  At  last  the  capsule  ruptures, 
and  the  blood  escapes  into  the  pelvic  cavity.  Monthly  hemorrhages 
then  take  place  from  the  ovarian  stroma,  with  a  corresponding  periodic 
increase  in  the  pelvic  accumulation,  with  all  of  the  attending  signs — 
pain  and  shock — of  hsematocele.  The  case  is  nearly  a  hopeless  one,  but 
at  any  of  the  periodic  exacerbations  does  not  present  specially  alarming 
symptoms.  This  theory  explains  in  a  very  perfect  manner  the  case 
reported  by  Madge. 

Richet,  D^valz,  Scanzoni,  and  Winckel  assign  to  a  varicose  condition 
of  the  subperitoneal  venous  plexus  of  the  ovary  and  tube  an  important 
etiological  relation  to  hsematocele.     Scanzoni  believes  the  condition  is  a 


JLKMATnchlj:.  7  JI 

rare  OIK- ;  Winckcl,  liowcvcr,  li-iiuvs  it  vcrv  licauliliilly  in  his  J)i>   J'nH,, 
Wciblich.  (//(/(iiir  [[A.  xxvii.  li«rs.  2,  3),  and  staU's  that  this  vaiiii.-i-  cou- 
(litinii   (»r  the   t)vai-iaii   venous   plexus    is    rr((|ii(iil  l\    iihi  with    in    imisI- 
niiii-t(  Ml  i-xaniinations. 

r>aii(ll  mentions  rai'e  eases  of  h;eniatoeeIe  in  whiiji  aionnd  ihe  nteniH 
and  in  the  Ial»ia  a  varicose  eondilion  (dihe  \-eins  was  ohsei-vcd.  'I'here 
is  no  donht  that  a  varicose  condition  ol"  the  parovarium  hits  hceii  fomid 
associated  with  the  ae<i(h'nt.  IJernutz  also  says  that  a  varicose;  dilata- 
tion ot"lhe  pamj)inirorm  may  occur  in  botli  the  [H'cj^nant  and  non-]ire<r- 
uaiit,  and  w  hen  carried  beyond  a  certain  limit  may  rupture.  A  luema- 
t(xvle  due  to  this  cause  ought,  iVoni  the  suddenness  with  wliich  such  a 
rupture  would  occur  and  the  ai)undant  source  of  the  hemorrhage,  to 
be  catastrophic,  as  Barnes  terms  it. 

It  was  first  asserted  by  Virehow,  and  reaffirmed  by  Dolbeau,  Huguier, 
and  Tardieu,  that  the  blood-eftiision  may  be  limited  to  the  peritoneum 
(peritonitis  luemorrhagica),  and  explained  by  Virciiow  as  a  process  simi- 
lar to  that  which  occurs  in  pachymeningitis  pseudo-mend)ranosa,  in  which 
a  liUe  exudate  is  uoticeil.  It  is  evidently  the  same  process  to  which 
Bandl  gives  the  name  of  pelvi-peritonitis  luemorrhagica.  The  same 
idea  has  gained  the  good-will  of  Bernutz,  who  regards  the  exudate  as 
the  homologue  of  that  in  the  hemorrhagic  pleurisy  of  Laennec.  A 
litematocele  due  to  this  cause  ought  to  present  some  differential  charac- 
ters in  marked  contrast  to  those  present  in  a  ha?matocele  due  to  sudden 
rupture  of  a  pelvic  ve&sel.  In  the  latter  the  pain  and  peritonitic  symp- 
toms follow,  and  in  the  former  the  peritonitis  ought  to  precede  the  effu- 
sion. This,  clinically  speaking,  is  just  what  does  not  occur.  AVhile  it 
cannot  be  denied  that  effusions,  such  as  are  here  described,  may  be  the 
residt  of  peritoneal  inflammation  of  a  certain  grade  in  any  situation 
where  the  membrane  may  be  met  with — while,  in  fact,  exudation  mav 
be  said  to  be  a  general  attendant  of  the  inflammatory  process  in  the  ]iart 
— still,  we  cannot  regard  it  as  a  common  cause  of  the  hrematoceles  that 
concern  the  gynecologist.  It  is  difficidt  to  conceive  of  a  pelvic  effusion 
justly  due  to  the  latter  cause  that  could  reach  such  a  point  in  its  devel- 
o])ment  that  it  woidd  be  clinically  proper  to  cease  to  regard  it  as  a  peri- 
toin'tis,  and  become  simply  a  hjcniatocelc.  Exudative  pelvic  peritonitis, 
in  which  the  effusion  is  organized  into  vascular  pelvic  adhesions,  may 
lead  to  hR?matocele — not,  however,  as  the  result  directly  of  the  perito- 
nitis, but  as  the  outcome  of  the  adhesions.  The  rupture  of  vascular 
adhesions  may  take  place  and  lead  to  a  very  active  intra]iclvic  hem- 
orrhage. This  accident  is  especially  liable  to  happen  if  old  uterine 
displacements  are  replaced  with  the  sound  or  with  an  instrument 
known  as  a  repositor,  which  has  now,  fortunately,  gone  nearly  out  of 
use.  It  is  a  common  matter,  after  a  forcible  re]ilaccment  of  a  distorted 
or  displaced  uterus,  for  a  pelvic  mass  to  quickly  form,  attended  with 


742  PELVIC  HMMATOCELE  AND  HEMATOMA. 

severe  paiu  and  rapidly-developiug  peritoueal  tenderness.  In  the  course 
of  several  weeks  or  months  the  mass  is  gradually  absorbed,  and  the  pain 
and  tenderness  in  like  manner  subside.  Such  a  case  is  usually  consid- 
ered as  a  new,  or  as  a  relapse  of  an  old,  cellulitis.  In  our  present 
knowledge  of  the  subject  of  hgematocele  it  is  certain  that  many  of 
these  cases  ought  to  be  considered  instances  of  this  accident.  Abdominal 
surgery  teaches  us  that  the  rough  handling  of  peritoneal  surfaces  adher- 
ent with  old  adhesions  is  not  specially  liable  to  cause  a  renewal  of 
inflammation.  With  this  experience  before  us  it  is  philosophical  to 
class  some  cases  of  this  character  as  hsematoceles. 

Emmet  holds  that  the  theory  of  Bernutz,  that  menstrual  blood  may 
regurgitate  through  the  tube  backward  into  the  peritoneal  cavity,  worth 
no  more  than  a  passing  notice ;  but  he  admits  that  Trousseau's  theory, 
that  the  source  of  the  hemorrhage  may  be  in  an  exhalation  from  the 
mucous  membrane  of  the  tube,  may  be  correct,  the  blood  coming  from 
that  portion  near  the  fimbriated  extremity.  Meadows,  in  commenting 
upon  this  theory,  gives  the  opinion  that  in  an  ordinary  state  of  the  tube 
such  a  thing  is  not  possible,  but  that  it  must  be  granted  that  the  tube 
is  dilated,  and  its  contents  forced  toward  the  fimbriae,  causing  the  spas- 
modic pain  characteristic  of  the  menstrual  variety  of  hsematocele.  Tait, 
without  any  qualification,  says  the  theory  is  improbable.  Very  few 
demonstrations  bearing  directly  upon  the  subject  are  recorded,  and  in 
both  cases  of  undoubted  regurgitation  mentioned  by  Brodie  and  Pauly 
there  was  occlusion  of  the  os  externum  uteri. 

Several  cases  have  been  recorded  of  dilatation  of  the  tube  in  instances 
of  double  uterus.  Deces  relates  a  case  of  double  uterus  and  vagina, 
with  the  left  vagina  imperforate,  with  accumulation  of  menstrual  blood 
in  the  left  uterus  and  vagina.  It  resulted  in  over-distension,  rupture, 
and  death. 

Barnes  has  a  group  of  heematocele  due  to  the  prevention  of  the  escape 
of  uterine  discharges  during  abortion.  In  these  cases  the  blood  is  forced 
along  the  tubes,  and  finds  its  outlet  into  the  peritoneum.  No  cases  have 
been  discovered  which  substantiate  this  theory.  Such  a  condition  may 
be  possible  in  traumatism  due  to  forced  abortion,  but  even  here,  from 
the  necessary  condition  of  things,  we  can  barely  admit  its  possibility. 

Spencer  Wells  states  that  blood  may  eflfiise  from  the  stump  of  an 
ovarian  cyst  when  treated  intraperitoneally.  Small  effusions  from  this 
source  are  very  common,  and  the  symptoms  slight.  When  the  ped- 
icle is  secured  externally,  blood  has  been  observed  to  percolate  from  its 
exposed  extremity  at  a  menstrual  period.  By  a  parity  of  reasoning,  we 
may  assume  that  the  same  condition  may  occur  when  the  pedicle  is 
treated  intraperitoneally,  and  thus  small  menstrual  hsematoceles  be 
formed.  It  is  doubtful  if  a  hsematocele  due  to  this  cause  would, 
clinically,  call  for  rigid  diagnosis. 


II.KMATOCF.LI':.  74;j 

l"'rc(|iii'iit  iiinitioii  is  made  1»\  many  aiMli<irs,  c-iKTiallN' ol' tin-  l''i-iiic|i 
scliool  (»r  ^TiH'('t'li>uy,  <»1"  sexual  iMici'coiiisc  at  a  infii>lnial  j»crit»»l  as  an 
rti()U)j2;ical  cDnditioii.  Scncii  cases  nnl  <il"  ten  nienti()ne<I  l»v  X'oisin  had 
the  tiixt  pains  at  tendinis'  the  aeeidcnt  (teeiM-  (hn'inu  coitus.  iSandl  rec(»r<l.s 
a  case  in  which  coitus  lirst  tooi<  place  at  the  ix-Liinnini:  ol"  menstruation, 
attemh'd  l)y  the  rapid  I'ornialion  ol  luemalocclc.  I'nech  also  cites  a  ease. 
W  c  can  readily  admit  what  a  potent  I'actoi- sexual  iiitefconrse  at  a  inen- 
sti'iial  pefiod  may  lie  as  a  cause  of  fuptufc  i»t'  inij)aifed  |iel\ic  hlood- 
vessels.  Too  rre(|uciit  of  too  violent  a  sexutd  act  is  also  mentioned  a.s 
an  excitinii'  cause;  hut  il"  any  eases  are  directly  ref'crahlc  to  this  cause, 
they  havi'  escapetl  demonstration. 

Severe  hodily  eiliirt  durint;'  menstruation  has  heen  known  to  ])recipi- 
tate  an  attack  of  pel\ic  heni()rrlia«»:e.  Heavy  liftinj^:,  daneiufr,  or  long 
jH'destiian  excursions  ou^ht  to  he  carefully  avoided  by  one  at  this 
})eriod  who  has  ever  been  subject  to  a  menstrual  hiematocele.  Sudden 
ehillino;  during  menstruation,  especially  of  the  extremities,  may  act  as 
an  exciting;  cause.  Bathing  the  feet  in  cold  water  at  such  a  time  has 
been  known  to  be  the  a]>pai'eut  cause  of  an  attack. 

Changes  in  the  constitution  of  the  blood  or  in  the  walls  of  blood- 
vessels after  acute  exanthenis  are  sometimes  the  cause  of  pelvic  accu- 
nmlations  of  altered  blood.  Bandl  names  purpura,  icterus  gravis,  scar- 
latina, and  variola  as  the  diseases  in  which  pelvic  j)eritoneal  affusions 
are  the  more  liable  to  occur.  Trousseau  calls  the  hrematocele  thus 
jissociated  the  cachectic.  In  a  strict  classification  of  etiological  condi- 
tions this  cause  ought  to  be  excluded.  The  morbid  condition  may,  and 
probably  docs,  extend  to  the  general  peritoneal  cavity  of  the  abdomen, 
and  the  blood  accunudates  in  the  pelvic  spaces  by  gravitation.  Clini- 
cally, a  ha-Muatocele  due  to  this  cause  would  rarely  claim  the  attention 
of  the  gynecologist. 

We  have  thus  gone  over  all  the  j>elvic  and  general  conditions  which 
may  act  as  near  or  remote  causes  of  this  serious  accident :  a  great  many 
are  rarely  acting  factoi-s ;  others,  however,  are  so  frequently  observed 
that  ordinarily,  without  going  into  any  method  of  rigid  exclusion,  we 
may  say  that  the  lesion  exists  in  the  circulatory  plexuses  of  the  ovaries 
and  tubes.  AVe  are  justified  in  saying  that  the  ovaries  are  periodically 
in  a  condition  favorable  to  the  accident.  As  Rokitansky  states  from 
actual  demonstration,  a  source  of  ovarian  hemorrhage  may  exist  in  a 
bui-sting  of  cysts  of  the  ovary  formed  of  distended  follicles  in  which 
l)lo(xl  has  been  extravasated — a  condition,  minus  the  ru])ture,  observed 
with  great  frequency  in  the  cadaver.  It  is  not  difiicult  to  undei-stand 
why  the  menstrual  group  of  pelvic  haematoceles  is  the  one  with  Avhich 
the  gynecologist  has  most  frequently  to  contend. 

Pathology.  —  Since  retro-uterine  and  anteuterine  hteraatoceles 
rarely   terminate    fatally,   many   of   the   early   pathological    conditions 


744  PELVIC  HEMATOCELE  AND  HuEMATOMA. 

are  obscure  and  are  largely  obtained  from  clinical  study.  Time  is 
not  measured  by  its  ordinary  periods  in  gynecology,  and  the  year 
1859,  when  Simpson  wrote  upon  hseraatocele,  while  near  in  the  matter 
of  years,  is  remote  in  view  of  the  rapid  advance  of  a  great  science; 
and  yet,  crowded  as  is  the  intervening  time  with  facts,  nothing  has 
been  added  to  the  truth  as  he  expressed  it,  that  "  there  is  almost  no 
limit  to  the  variety  of  the  situations  in  which  a  pelvic  thrombus  or  a 
hsematoma  may  be  found,  for  the  veins  may  give  way  in  any  part  of 
the  pelvis,  and  the  blood  which  escapes  may  fill  sometimes  one  facial 
loculament  only  of  the  pelvis,  at  other  times  several  at  once."  Snow 
Beck  says  that  the  arrangement  of  the  fascia  in  the  pelvis  covering  the 
various  muscles,  and  converging  to  a  central  part  at  the  neck  of  the 
uterus,  is  very  complicated,  and  often  presents  a  weak  point  behind  the 
OS  internum,  into  which  the  finger  can  be  pressed  and  through  which 
a  hernial  protrusion  of  the  veins  may  occur.  This  was  the  seat  of  an 
effusion  observed  by  him.  There  are  other  and  less  complicated  rea- 
sons why  the  hsematic  affusion  is  generally  noticed  in  the  recto-uterine 
pouch.  The  Fallopian  tubes  are  always  directed  backward,  never  for- 
ward, so  that  a  blood-effusion  naturally  takes  the  direction  downward 
and  backward.  Periuterine  and  anteuterine  hsematoceles  are  usually 
secondary  to  retro-uterine  hsematocele,  or  when  anteuterine  hematocele 
exists  without  the  retro-,  it  is  because  Douglas's  space  is  obliterated  by 
adhesions  and  fibrous  bands,  so  as  to  prevent  the  accumulation  at  this 
point.  A  case  recorded  by  Schroeder  demonstrates  this  fact.  While, 
however,  the  ovaries  and  tubes  lie  mostly  in  the  posterior  wings  of  the 
broad  ligaments,  and  the  escaping  blood  most  easily  finds  its  way  into 
the  recto-uterine  duplicature  of  the  peritoneum,  it  is  a  mistake  to  sup- 
pose that  all  blood  so  effused  will  do  this  if  this  cavity  is  free.  Small 
blood-masses  will  become  entangled  in  the  vesico-uterine  pouch  or  even 
lie  above  the  broad  ligament.  These  are  marked  exceptions  to  the  rule, 
which  may  be  said  to  hold  true  when  Douglas's  space  is  free. 

Courty  says  that  if  the  hemorrhage  comes  from  the  tubes  or  ovarian 
venous  plexus,  the  resulting  hematocele  may  be  limited  to  the  folds 
of  the  broad  ligament,  or  under  the  peritoneum  covering  the  uterus, 
in  periuterine  cellular  tissue,  not  only  behind  and  in  the  broad  ligament 
of  the  other  side,  but  also  in  front  under  the  peritoneal  fold  covering 
the  uterus  and  bladder.  These  limits  of  the  haematic  tumor  define  the 
hsematoma  rather  than  the  hematocele,  and  the  disposition  of  the  blood 
affused  into  one  broad  ligament  to  pass  over  to  the  other  develops  the 
central  constriction  in  the  tumor,  to  which  considerable  importance  is 
given  in  the  differentiation  of  the  two  forms  of  pelvic  effusions. 

Emmet  defines  three  sources  of  hemorrhage.  The  first  is  from  the 
mass  of  vessels  known  as  the  bulb  of  the  ovary,  from  which  the  blood 
would  pass  into  the  peritoneal  cavity ;  second,  from  the  pampiniform 


ILEMAToci.U:.  71,-, 

plt'Xiis  Mini  iHluork  of  vosH'ls  iiii(l<  r  tlir  tiilxs  aii<l  Ixf  wtM-n  tin-  folds 
ui"  the  l)i-u;i«l  liirMlilcllts,  :ill<l  llilis  tlir  «'sr;ijM-  wuiild  (K-ciir  ill  tin-  <«lliilar 
tissue  (»r,  l)y  niptiir.-  of  the  |Hi-itoiii'Uin,  jkuvs  into  the  ^-avity  of  the  alwlo- 
nu'ii  ;  tliinl,  fn»in  the  vatj^iiial  jmictioii  at  l)ottoiii  «tf  Doufrhis's  s|>a<f, 
at  the  point  (Icscrihcd  by  Snow  !i«c|<,  or  from  sonic  point  in  front  of 
tlic  iitcnis,  l)iit  out.sidf  ol"  the  jx  ritoiu  iim,  from  wliidi  point  tiic  cHii.sion 
would  be  fonfincHl  to  the  (cIlMlar  tis-iic  The  tir-t  sourrc  of  hcmorrlijijje 
would,  LT^'uerally  speak i nir,  uivc  oi-itrin  to  tin-  menstrual  variety  of  liuMii- 
atoeele,  and  the  seeoud  and  third  to  the  forms  usiiallv  found  iLss«KMat(xl 
with  eliildhirth  or  abortion.  Most  frequently  the  extravasation  of  blood' 
into  the  pelvic  cellular  tissue,  known  as  luematoma,  results  from  ru])ture 
of  the  pamj)iniforni  plexus  or  the  venous  auiLstomoses  of  the  broad 
litrameuts,  and  not  from  the  ovaries.  Rupture  of  the  vessels  in  the 
vaginal  roof  is  irenerally  due  to  traumatism,  such  as  foreed  abortion 
or  j>elvie  operations. 

The  ovaries  have  been  found  degenerated  and  ])artially  converte<l  into 
soft,  dark-red  capsules  capable  of  pouring  out  considerable  quantities  of 
blood,  and  in  this  form  associated  with  retro-uterine  luematcxele.  In 
the  section  upon  Cause  a  varicose  condition  of  the  venous  plexus  of  the 
ovary  or  broad  ligament  has  been  noticed — a  condition  found  in  child- 
bearing  women,  and  of  which  a  varicose  condition  of  the  labia  majora 
may  be  taken  as  a  type.  If  in  these  cases  the  peritoneum  were  to  give 
way  a  haematocele  woidd  result ;  and,  on  the  contrary-,  such  rupture 
of  the  vessels  has  been  observe<l  with  the  peritoneum  intact,  with 
haematoma  as  the  result.  Xelaton  believed  that  blood  might  escape 
spontaneously  from  the  ovaries  during  menstruation. 

In  over-exertion  during  menstruation  blood  can  esca})e  from  the  cor- 
pus luteuni  in  certain  morbid  states  of  the  organ.  Ajioplexy  of  the 
ovary,  mentioned  by  Scanzoni,  may  possibly  be  a  condition  that  would 
favor  hemorrhage  from  the  organ  in  the  condition  last  mentioned.  The 
case  on  which  his  theory  of  apoplexy  is  based  is  not  of  that  character. 
In  the  instance  of  an  eighteen-year-old  girl  Avho  died  from  a  rapid 
pelvic  hemorrhage,  the  section  showed  the  right  ovary  the  size  of  a  hen's 
egg,  with  a  large  bloml-cyst  in  the  posterior  wall,  in  Avhich  was  a  rup- 
ture one  inch  long,  through  which  the  blood  had  escaped.  Blorxl- 
thrombi  in  the  connective-ti.ssue  stroma,  usually  quite  small,  or  small 
cysts,  are  not  rarely  observed.  Bandl  gives  to  these  imjwrtant  patho- 
logical value. 

The  tubes,  aside  from  rujiture  due  to  over-distension,  are  sometimes 
sul)ject  to  changes  which  may  result  in  hemorrhage.  Occlusion  of  the 
uterine  extremity  of  the  tube  has  been  observe<l.  Barlow  reports  such 
a  case  where  the  tube  was  distendetl  with  the  clot  protruding  from  the 
ovarian  extremity.  Scanzoni  mentions  a  like  case,  with  the  tube  dis- 
tended to  the  size  of  the  finger,  holdinir  two  ounces  of  bloo<l.  mIhIc 


746  PELVIC  HEMATOCELE  AND  HEMATOMA. 

sixteen  ounces  had  escaped  into  the  peritoneal  cavity.  Bandl  roughly 
generalizes  that  when  the  ovary  is  normal  the  pathological  change  is 
located  in  the  tube.  The  reader  is  now  prepared  to  realize  that  no  such 
broad  generalization  can  be  made — that^  as  a  matter  of  fact,  if  the  ovary 
is  normal  the  source  of  hemorrhage  is  usually  found  in  some  of  the 
numerous  venous  congeries  of  the  uterus  or  broad  ligament.  Vigues 
has  stated  that  every  hsematocele  is  caused  by  a  tubal  pregnancy.  Gal- 
lard  also  adheres  to  this  theory.  Hsematocele  very  frequently  follows 
a  two  months'  lapse  of  menstruation,  and  often  after  a  recent  delivery. 
Frequent  childbearing  is  associated,  either  as  a  cause  or  a  result,  with 
narrowed  and  dilated  tubes.  As  a  further  proof  of  this  theory,  tubal 
moles  or  blighted  ovum  have  been  noticed.  In  some  cases  a  decidua 
has  been  found.  There  are  several  cases  of  extra-uterine  mole  preg- 
nancies on  record.  Prof.  Heschl  placed  a  typical  instance  of  this  at 
Bandl's  disposal,  preserved  at  the  Vienna  Pathological  Museum.  Two 
other  cases  of  like  nature  have  been  preserved,  while  Duverney  also 
described  a  case.  The  fact  that  tubal  pregnancy  can  cause,  and  unfor- 
tunately has  caused,  pelvic  haematocele  of  a  catastrophic  character  jDer- 
mits  no  kind  of  doubt,  and,  from  possessing  altogether  another  kind  of 
interest  to  the  gynecologist  foreign  to  this  subject,  has  been  excluded  as 
a  cause  from  this  article.  It  is  a  matter  of  direct  interest  to  the  sub- 
ject that  this  form  of  pregnancy  may  result  in  a  mole  and  be  a  source 
of  danger  for  an  indefinite  time.  We  must  regard  it  as  placed  beyond 
a  doubt  that  this  termination  has  taken  place,  and  has  not  placed  the 
subject  exempt  from  dangers  which  are  regarded  as  the  direct  and  cer- 
tain outcome  of  tubal  pregnancy  with  normal  development  of  the  ovum. 
Destruction  of  the  ovum  by  electricity,  with  a  mole  degeneration  of  the 
bliglited  product,  may  be  a  result  of  the  use  of  this  very  certain  way 
of  arresting  foetal  growth. 

Courty  considers  the  anteuterine  variety  of  haematocele  secondary  to 
the  retro-uterine.  If  the  recto-uterine  pouch  is  too  small  to  contain  the 
effusion,  both  varieties  will  form.  G.  Braun  notes  a  case  in  which  a 
tumor  15  cm.  long  developed  in  the  utero- vesical  space.  The  bladder 
was  forced  doAvnward  and  backward  in  the  vagina.  On  examination 
after  death  peritonitis  was  marked ;  a  sac  as  large  as  a  child's  head 
occupied  the  anteuterine  space ;  behind  and  below  it  was  bounded  by 
the  ligamentum  latum  and  the  uterus,  on  the  left  by  the  mesentery  and 
sigmoid  flexure,  in  front  and  above  by  the  adherent  small  intestines, 
mesentery,  and  the  greater  omentum.  Braun  remarks  that  after  adhe- 
sions of  the  extent  and  character  noted  a  large  space  was  left  in  the 
region  of  the  utero-vesical  space  that  could  be  occupied  by  a  haemato- 
cele. Schroeder  examined  a  like  instance  in  which  the  rupture  of  a 
tubal  pregnancy  gave  origin  to  an  anteuterine  haematocele.  Douglas's 
space  was  obliterated  by  strong  adhesions  which  confined  the  uterus 


ILKMArocilLE.  7  17 

haclvward.  Sclirocdcr's  idea  was  tliat  llic  atllirsiuiis  <»!'  (lie  iitcni>  wiih 
the  rectum,  aii<l  tlu'  resulting  displaeement  backward  of  tlir  orj^an, 
were  primary  t<»  tlie  I'ormatiun  ol'  the  ha'matdceh',  tliiis  (•aii>iiin;  a  large 
space  to  he  occupied  hy  the  exlravasated  hlood  in  tlie  aiilcutci-ine  region. 
Reiusouing  from  the  great  Imjueney  with  wliidi  adhc-ions  and  conse- 
quent obliteration  of  Doughus's  sac  are  observed,  we  must  admit  that 
it  is  a  very  })rol)ablc  antecedent  of  h.ematocele.  (ii\-cn  this  condition, 
tliere  is  but  one  other  pelvic  space  that  c(ndd  be  occupied  bv  anv  con- 
siderable blood-accumulation.  While  we  achnit  a  perinteiine  jxritoni- 
tis  may  be  jtrimary  to  any  pelvic  effusion,  it  certainly  does  not  afford 
grounds  for  the  broad  generalization  that  the  extensive  adhesions  that 
encaj)sulate  the  haematic  tiniior,  and  give  origin  to  the  name  of  h:ema- 
toeele,  are  always  a  condition  that  exists  jn'ior  to  the  jielvic  hemorrhage. 
Schroeder  is  inclined  to  this  view  of  the  matter,  while  Braun  also 
expresses  the  same  (^pinio.n  in  the  case  quoted  from  Iiim.  Xelaton  says 
that  the  formation  of  the  blood-tumor  is  the  j)rimarv,  and  the  perito- 
nitis with  pseudo-membrane  and  adhesion  of  near  parts  the  secondary, 
steps  in  the  process.  The  argument,  on  the  other  hand,  tliat  experi- 
ments with  animals  by  injecting  blood  into  the  ])eritoneal  sac  do  not 
result  in  exciting  peritonitis  and  encapsulation  of  the  foreign  blood-clot 
by  adhesions,  is  not  valid,  and  furnishes  no  grounds  for  a  like  conclu- 
sion in  the  human  subject,  in  Mhich  mc  have  to  deal  with  a  morbid 
process  from  the  beginning  to  the  end  of  a  pelvic  htematocele.  In  the 
human  subject  we  have  not  alone  the  l)lood-clot,  l)ut  an  altered  state  of 
the  secretions,  a  lowered  vital  tone  incident  to  the  hemorrhao-e,  and  the 
primary  tissue-changes  which  made  the  entire  series  of  morbid  events 
poasible.  These  conditions  can  never  ol)tain  in  animal  experiments. 
We  must  come  to  the  conclusion  that  the  ])entonitis  and  adhesions 
which  form  such  a  striking  phenomenon  in  true  pelvic  haematocele  are 
the  results  of  the  pathological  conditions  which  have  their  origin  in  the 
pelvic  blood-accumulation  with  its  primary  morbid  tissue-alterations. 
This  conclusion  must,  however,  be  modified  to  the  extent  of  admitting 
that  a  pelvic  peritonitis  Avith  adhesions  and  distortion  of  the  pelvic 
organs  may  precede  the  occurrence  of  pelvic  blood-accunudation,  but 
that  such  a  condition  is  a  coincident,  and  not  in  any  ^vay  a  link,  in  the 
chain  of  diseased  sequences  related  to  the  h;emat(X'ele,  except  as  the 
previous  existence  of  the  pelvic  inflammatory  process  may  favor  the 
occurrence  of  rupture  of  some  pelvic  blood-vessel.  A  more  careful 
study  of  the  haematic  sac  affords  additional  evidence  of  the  truth  of 
this  argument. 

Generally,  quite  rapidly  after  the  formation  of  the  pelvic  clot,  symp- 
toms of  peritonitis  develop.  If,  in  a  week  to  three  weeks  after,  a  post- 
mortem examination  is  made,  the  clot  is  found  surrounded  by  a  false 
membrane,  which  has  been  mistaken  for  jieritoneum.     This  pseudo- 


748  PELVIC  H.EMATOCELE  AND  HJEMATOMA. 

membrane  throws  out  filamentous  prolongations  which  pass  through  the 
mass,  while  other  extensions  from  it  resemble  bands  of  connective  tissue 
and  pass  through  the  clot  like  partitions.  In  other  instances  no  fibrin- 
ous bands  of  adhesions  are  formed,  but  a  membranous-like  covering 
spreads  over  the  blood-mass.  In  other  cases  the  enveloping  process 
consists  in  a  welding  together  of  intestinal  loops.  An  instance  of  this 
has  been  described  above  in  relation  to  a  case  of  anteuterine  haematocele. 

In  retro-uterine  blood-collections  the  following  boundaries  are  usually- 
noticed  :  The  broad  ligaments  and  the  uterus  are  above  and  in  front, 
behind  is  the  rectum  with  the  contiguous  peritoneum,  below  the  utero- 
rectal  pouch,  and  above  it  is  bounded  by  agglutinated  loops  of  small 
intestine.  In  cases  of  retro-uterine  haematocele  with  a  well-defined  his- 
tory of  antecedent  pelvic  inflammation  the  following  boundaries  were 
observed  by  Voisin  :  Below  the  recto-uterine  pouch,  above  the  broad 
ligament  and  the  sigmoid  flexure,  and  sometimes  the  small  intestine. 
These  cavities  are  of  a  great  variety  of  forms — sometimes  winding, 
sometimes  ovoid  Avith  inter-opening  spaces — and  have  a  capacity  of 
one-half  pint  to  five   pints. 

The  contents  of  the  sac  of  the  hsematocele  present  quite  a  uniform 
character,  according  to  the  stage  at  which  it  is  observed.  In  its  early 
history  it  is  simply  blood,  which  rapidly  undergoes  changes.  At  first 
it  acquires  a  greater  consistency,  due  probably  to  a  loss  of  a  portion  of 
its  serum  by  absorption,  and  of  a  tar-like  color.  At  a  later  stage 
Huertaux  found  (1)  drops  like  oil  of  a  brow^n  or  yellow  color;  (2) 
spherical  cells,  entire  or  reduced  to  fragments,  abounding  in  adipose 
nucleoli ;  (3)  amorphous  fragments  of  hsematoidin ;  (4)  quadrilateral 
crystals  resembling  ammonio-magnesian  phosphate;  (5)  some  blood- 
globules  darkly  stained;  and  (6)  a  great  quantity  of  blackish  corpuscles 
resulting  from  altered  blood.  In  other  instances  the  tar-like  blood  is 
largely  mixed  with  pus  and  sanies.  Rindfleisch  found  in  the  contents 
serrated  and  shrunken  blood-corpuscles,  rarely  any  fresh,  numerous 
white  blood-corpuscles  or  pus-globules,  with  epithelial  and  granular 
cells. 

The  pelvic  hsematoma  differs  totally  in  its  surroundings  from  the 
hsematocele.  In  some  instances  the  peritoneum  is  stripped  off  from  the 
underlying  parts  and  the  space  occupied  by  the  extravasated  blood ;  in 
others,  as  in  the  duplicatures  of  the  broad  ligament,  two  peritoneal  sur- 
faces are  wedged  apart  by  the  blood-mass ;  while,  again,  the  cellular 
tissue  affords  space  for  the  extravasation.  From  the  nature  of  these 
surroundings  the  hsematoma  is  always  of  less  extent  than  the  hsemato- 
cele, and  as  a  rule  unattended  with  adhesive  peritonitis  and  the  agglu- 
tination of  the  near  parts.  If  found  associated  with  obliteration  of 
pelvic  peritoneal  spaces  by  adhesions,  that  condition  is  probably  a  prior 
matter  to  the  development  of  the  hsematoma.    The  displacement  exerted 


JLr.MAroCF.I.K. 


7I!> 


l)y  the  hii'inatic  tumor  upon  (•»»iitiiiiiuus  (ir<r;iii.s  also  (litters  from  that  of" 
tlu'  hiomatocek',  wliidi  will  l)e  luttici-d  later  when  upon  the  snliject  ot" 
(litl'erentiatioii  of"  the  two  (•on(liti<»ns. 

( 'haiiiic's  in  the  contents  of "  a  hiematoma  are  less  rapid  than  in  ha-nia- 
toeele.  It  is  dillienlt  to  ex})lain  this,  unless  it  is  done  by  the  assiini|ition 
that  the  hlood  is  more  elfeetually  sealed  from  sej)tic  inHuenees  external 
than  internal  to  the  peritoneal  sac  Of  course  the  marked  jx-ritonitis 
that  attends  the  luematocele  may  atld  both  raj)idity  and  mali<:nancv  to 
the  changes  that  take  place  in  the  contents  of  the  latter.  Altered  hlood, 
simies,  j)us,  are  found  that  do  not  materially  differ  from  those  already 
described.  M'hen  the  extravasiition  is  situated  between  the  folds  of  the 
broad  ligament,  adhesion  to  near  ])arts  has  been  observed,  but  not  to  the 
same  extent  as  in  hienuitocele.  Silvestre  found  in  the  rio-ht  liffamentum 
lata  a  cavity  filled  with  blood  which  communicated  with  the  cavitv  of 
a  thrombus  behind  the  uterus.  The  jieritoneal  surfaces  were  changed 
by  the  deposit  of  lymph  and  injected  vessels.  This  example  shows 
that  these  jielvic  blood-tumors  may  coexist,  and  probably  have  their 
origin  at  the  same  time,  while  their  cavities  may  communicate.  Clinic- 
ally, it  would  be  impossible  to  form  any  opinion  as  to  this  coexistence. 
Such  a  condition  may  occiu'  more  frequently  than  the  isolated  case  of 
Silvestre  Avoukl  give  grounds  to  believe,  as  the  extensive  massing 
together  and  alteration  of  the  tissues  would  render  the  recognition  of 
the  complication  difficult  if  not  impossible. 

An  instance  of  hsematoma  of  the  ovary  was  submitted  to  the  writer 
by  Dr.  C.  E.  Billington,  a  coroner,  for  opinion.  The  si^ecimen  was 
taken  from  a  woman  thirty  years  old,  who  had  died  after  a  suspected 
criminal  abortion.  The  uterus  was  about  four  inches  long,  its  walls 
thickened,  soft,  and  the  inner  layers  of  its  parenchyma  deejily  injected, 
with  evidences  of  fatty  degeneration.  The  right  ovarv  had  upon  its 
upper  surface  a  cyst  as  large  as  a  pigeon's  qo^q:,  covered  by  the  perito- 
neum on  the  outer  one-third  of  its  surface,  and  the  remainder  of  the 
circiunference  embraced  by  the  structure  of  the  organ.  It  was  filled 
with  dark  coagulated  blood.  There  were  evidences  of  general  jierito- 
nitis,  but  no  mention  was  made  of  pelvic  adhesions.  The  affusion  was 
but  a  few  days  old,  judging  from  the  appearance  of  the  l)lood-clot, 
which  was  quite  fresh.  While,  in  our  present  knowledge  of  the  sub- 
ject, we  could  not  regard  the  hsematoma  as  an  evidence  of  forced  alior- 
tion,  the  assumption  is  projier  that  it  was  the  result  of  violence  to  the 
pelvic  organs.  If  this  sac  had  ruptured  Avhile  the  hemorrhage  was  in 
progress,  it  would  have  been  an  examjile  of  a  hsematoma  passing  into 
a  haMnatocele. 

Poncet  states  that  in  old  sacs  the  contents  become  jiartly  organized 
with  bands  of  false  membranes  and  strata  of  fibi-in,  resembling  the 
condition  of  old  aueurismal  sacs.     This  condition  is  rare. 


750  PELVIC  HEMATOCELE  AND  HEMATOMA. 

Emmet  says  that  if  the  term  is  confined  to  blood -accumulations  in 
the  peritoneal  cavity,  the  disease  is  a  rare  one,  but  if  held  to  embrace 
all  blood-accumulations  in  the  pelvis,  the  disease  is  more  common  than 
is  generally  supposed.  It  is  frequently  mistaken  for  a  pelvic  cellulitis. 
Escape  of  blood  in  small  amount  into  the  connective  tissue  may  be 
like  an  attack  of  cellulitis  in  suddenness  of  symptoms ;  and,  on  the 
other  hand,  such  small  cellular  effusions  may  exist  without  symptoms. 
Emmet  has  detected  large  accumulations  going  on  in  the  peritoneum 
without  causing  the  patient  any  discomfort.  Cellular  effusions  of  this 
minor  character  are  more  frequent  midway  in  the  menstrual  life,  espe- 
cially in  those  who  have  borne  a  number  of  childi'en  in  rapid  succession. 
That  the  hsematocele  may  exist  without  marked  symptoms  and  without 
pathological  traces  is  not  to  be  doubted.  Barnes  says  that  the  remains 
of  slight  pigmentation  in  Douglas's  sac  are  very  frequent,  assuming, 
of  course,  that  such  appearances  indicate  the  presence  of  old  effu- 
sions. 

There  is  yet  a  wide  field  for  study  in  the  pathology  of  these  interesting 
accidents.  On  many  points  we  are  yet  in  doubt.  There  has  been  too 
much  theory  and  too  little  demonstration  of  actual  conditions.  Upon  no 
subject  have  there  been  more  voluminous  contributions  made  of  learned 
speculations,  and  yet  so  little  actually  settled. 

Symptoms  ajstd  Course. — McClintock  makes  three  symptomatic 
groups  :  First,  the  severe,  the  cataclysmic  of  Barnes  ;  second,  the  more 
moderate  seizures,  though  plainly  marked;  and  third,  the  chronic  form 
— the  symptoms  being  developed  gradually  and  in  succession,  and  being 
liable  to  be  confounded  with  pelvic  abscess  or  ovarian  tumors.  The 
marked  symptoms  belong  to  the  initiative  stages  and  attend  the  extrav- 
asation of  blood.  The  symptoms  of  the  first  group  are,  first,  the  shock 
of  pain  and  blood-loss ;  second,  the  reaction ;  third,  the  inflammation. 
The  attack  opens  with  a  severe  and  sharp  pelvic  pain,  generally  well 
localized,  but  sometimes  diffused  over  the  abdomen.  Associated  with 
it  is  a  more  or  less  profound  shock,  the  features  pinched  and  blanched, 
the  expression  anxious,  the  pulse  rapid  and  thread-like,  the  surface 
bedewed  with  cold  sweat.  In  this  condition  the  patient  is  found.  For 
the  first  day,  about  in  the  following  order,  we  would  notice  that  the 
abdomen  was  distended ;  the  least  movement  would  cause  more  or  less 
violent  pain  ;  vague  shiverings  or  absolute  chill ;  fever  to  102°  to  104°; 
pulse  small  and  concentrated,  from  100,  120,  to  140  per  minute;  nau- 
sea, at  times  vomiting,  sometimes  uncoercible;  the  face  continues  pallid, 
expression  anxious ;  the  flesh  soft  and  flabby.  She  rarely  loses  intelli- 
gence, and  coma  is  extremely  rare.  The  position  is  dorsal,  avoiding  all 
movement.  After  about  the  first  twenty-four  hours,  these  extreme 
evidences  amend ;  the  nausea  and  vomiting  cease ;  the  pulse  loses  its 
frequency,  but  is  still  above  the  normal ;  the  face  is  less  pinched,  but 


Il.h.MATOCh'LK  701 

is  still  tliin,  ami  has  a  caclu'ctic  look,  like  llmi  in  iiinli^iiiint  (iinior. 
Tlu'  pain  is  t"r('»|ii('ntly  of  a  neuralgic  diaractcr,  anil  sonictinics  <»1" 
(li'sjK-nitr  iiitfiisity.  In  one  casi!  mentioned  hv  I'oncct  the  jiain  was 
in  the  ri<;ht  side,  the  anus,  the  thi^h,  the  heel,  and  would  then  transfer 
itself  without  apparent  cause  to  the;  opposite  side,  and  then  a<i:ain  shift 
in  sueeessitin  to  its  former  points,  as  is  sometimes  seen  in  the  evanescint 
pain  of  hysteria.  Ju  sjjite  of  most  active  treatment  the  pain  will  per- 
sist for  two,  three,  (M-  four  days.  The  bad  general  condition,  the  pro- 
found antemia,  and  the  excited  mental  state  tend  to  prolong  the  neur- 
algia, and  render  it  resistant  to  all  treatment.  As  this  neuralgic  con- 
dition is  a  feature  of  the  attack  prior  to  the  introduction  of  the  pain 
that  is  characteristic  of  the  inflammatory  stage,  it  is  probably  due  to 
the  blood-loss  and  the  intrapelvic  pressure,  and  gradually  subsides  a.s 
the  system  becomes  adjusted  to  the  loss  of  blood  and  the  nerves  habit- 
uated to  the  pressure  of  the  pelvic  mass.  Due  imj)ortance  will  be 
given  to  intrapelvic  pressure  when  we  reflect  that  in  no  other  accident 
to  which  woman  is  liable  can  such  a  pelvic  mass  Ije  developed  so  rap- 
idly. This  profound  nervous  disturbance  causes  yet  further  phenom- 
ena which  prove  its  far-reaching  character.  The  intestinal  strangula- 
tion M-hicli  has  been  noticed  has  by  some  been  explained  by  the  com- 
pression of  the  tumor  upon  the  intestines;  but  it  has  been  observed, 
too,  soon  after  the  effusion,  before  the  coagulation  of  the  blood  and 
before  the  onset  of  inflammation,  to  be  explained  as  the  result  of 
pressure.  Poncet  has  for  it  a  better  explanation,  regarding  it  as  due 
to  paralysis  of  the  muscular  layer  of  the  intestines,  and  calling  it 
pseudo-sti'angulation. 

A  very  common  form  is  attended  with  a  monthly  exacerbation  of  the 
symptoms.  There  are  increase  in  size  of  the  abdomen,  tenderness  on 
pressure,  pain,  and  febrile  reaction,  defecation  difficult  and  very  pain- 
ful. This  periodical  renewal  of  the  attack  has  been  explained  by  a 
return  of  the  hemorrhage  at  each  period,  and  defines  the  menstrual 
variety-  of  ]>elvic  hrematocele.  AVhen  the  tumor  is  large  we  generally 
have  vesical  tenesmus  or  micturition  is  difficult,  so  that  the  catheter  is 
necessar}\  Hart  and  Barbour  say  that  actual  retention  is  rare  in  the 
retro-uterine  variety.  This  symptom  is  quite  common  in  the  ante- 
uterine  form,  and  is  probably  due  to  mechanical  causes,  as  the  1)ladder 
is  forced  downward  and  backward,  doubled  upon  itself.  Vesical  catarrh 
is  frequently  noted,  Voisin  has  observed  in  a  number  of  cases  a  dysen- 
tery occur  at  irregular  intervals,  and  considers  it  of  utility  in  favoring 
absorption.  This  description  defines  the  acute  form  of  pelvic  haeraato- 
cele.  In  its  more  chronic  development  the  first  feature  to  attract  atten- 
tion would  be  the  attack  of  more  or  less  severe  pain,  severe  abdominal 
tenderness,  not  much  if  any  distension,  with  possibly  a  normal  tem- 
perature, and  possibly  difficult  defecation  and  sense  of  fulness  in  the 


752  PELVIC  HEMATOCELE  AND  HMMATOMA. 

pelvis,  with  the  detection  of  a  tumor  in  Douglas's  sac  if  an  examina- 
tion is  made. 

The  jjatient  may  be  upon  her  feet  before  the  exjiiration  of  a  mouth, 
but  at  the  next  menstrual  period  the  attack  recurs,  it  may  be  with 
greater  severity.  If  the  pelvis  is  again  examined,  the  retro-uterine 
tumor  is  again  observed,  increased  in  size  over  that  first  detected,  and 
with  more  marked  general  disturbance.  Thus,  month  after  month 
there  are  repeated  attacks  until  the  patient  is  brought  into  an  exceed- 
ingly dangerous  condition.  This  train  of  periodic  symptoms  simply 
defines  a  repeated  pelvic  hemorrhage. 

One  of  the  most  remarkable  features  of  an  attack  of  pelvic  hsema- 
tocele  is  the  tumor  itself.  Speaking  of  this  in  its  early  development, 
McClintock  says :  "  We  may  satisfy  ourselves  that  it  contains  fluid,  but 
whether  this  fluid  be  blood,  serum,  or  pus  cannot  be  determined  by  the 
most  delicate  sense  of  touch."  The  sudden  filling  ujd  of  the  pelvis,  the 
rapid  distension  of  the  abdomen,  the  vesical  and  rectal  symptoms  mark- 
ing the  great  displacement  of  the  pelvic  viscera,  are  traits  that  in  the  acute 
hsematocele  define  it  from  nearly  every  pelvic  accident.  Strange  to  say, 
however,  even  in  this  marked  form  the  pelvic  tumor  may  afford  matter 
for  serious  doubt.  Nearly  every  writer  upon  the  subject  agrees  that 
the  pelvic  tumor  can  be  felt  from  the  earliest  moment  in  the  history  of 
the  case.  Instances  by  Sireday,  Aran,  and  Bernutz  show  that  this  may 
not  be  so,  and  McClintock  first,  and  Tait  later,  have  shown  that  it  can- 
not be  so.  Blood  when  it  is  first  efiiised  does  not  coagulate,  and  with- 
out coagulation  we  cannot  have  an  intrapelvic  or  abdominal  mass.  A 
fluid  free  in  the  abdominal  cavity  cannot  give  the  defined  limits  of  a 
tumor.  A  small  collection  would  give  doubtful  evidences  of  fluctua- 
tion. There  is,  therefore,  a  pause  in  the  stage  of  development  when 
the  attack  is  free  from  the  local  evidences  of  pelvic  tumor.  This 
embraces  the  period  from  the  beginning  of  the  attack  until  the  coagu- 
lation of  the  effused  blood.  The  rapid  distension  of  the  abdomen 
observed  in  some  cases  is  probably  due  to  meteorism,  which  has  its 
origin  in  the  profound  nervous  disturbance,  as  when  the  more  acute 
symptoms  subside  on  the  second  day  this  general  abdominal  distension 
is  much  less.  We  are  to  look  independently  of  this  for  the  tumor, 
Avhich  will  be  found  occupying  the  Douglas  space  toward  the  end  of 
the  first  day.  This  matter  has  now  been  so  positively  stated  by  the 
excellent  authority  of  McClintock  and  Tait  that  this  error  should  be 
eliminated  from  the  textbooks. 

A  consideration  of  the  tumor  naturally  brings  us  to  a  study  of  the 
subject  of  physical  exploration,  which,  in  view  of  the  exhausted  and 
threatening  condition  of  the  woman,  has  to  be  practised  with  peculiar 
care.  When  the  retro-uterine  mass  is  small,  Tait's  method  of  pelvic 
exploration  is  an  excellent  one,  as  the  abdominal  rectal  or  vaginal 


HEMATOCELE.  753 

(loiiMc  touch,  wliicli  is  ('>|)('ci;ill\-  iKiiiiliil,  iii:i\'  l)c  avoided.  W  iili  the 
woman  ii|toii  her  Ictl  side  tlic  li-t'i  index  tin;;('r  is  iiiii-odnccd  into  tlic 
rtH'tiini,  and  tlu'  tliiinil)  ol"  (lie  same  liand  into  tlie  vagina,  or  with  the 
woman  upon  her  hack  tiie  rii;ht  index  may  ix'  \\>(-i\  I'oi' the  I'ectal  exjilo- 
ratioii  and  the  riiiht  tliiimi)  for  tlie  va^inah  In  this  way  tlie  thickness 
and  density  ol"  the  tumor  in  the  Douglas  sj)aee  may  he  eiearlv  made 
out  more  reailiiv  than  1)\'  anv  other  method,  as  well  as  its  non-connec- 
tiou  with  the  uterine  hody  and  ei'rvix.  By  the  vaij;inal  touch  we  show 
the  marked  forward  displacement  of"  the  uterine  hodv.  Jn  the  instance 
of  lai'u'cr  j)i'l\'ic  masses  the  ahdomcn  is  eidari^cd  and  rfinnde<l,  and  the 
tumor  may  be  i'elt  approach ini;-  the  umhilieus  and  spreading-  towai'd  the 
ilia.  ]iy  vaginal  exploration  we  discover  a  condition  closely  resembling 
a  retroversion  of"  tlu'  gravid  uterus  at  thi-ce  oi-  I'onr  months  (Barnes). 
The  finger  cannot  enter  the  hollow  of  the  sacrum,  because  it  is  occupied 
by  the  retro-uterine  mass.  The  posterior  vaginal  wall  is  dis])laced  for- 
ward and  the  direction  of  the  canal  altered ;  following  the  vagina,  the 
finger  passes  forward  and  enters  the  anterior  vaginal  fornix,  Avhich  is 
diminished  to  a  narrow  space  behind  and  above  the  symphysis  pubis, 
where  we  find  the  cervix  uteri  closely  compressed  against  it,  some- 
times even  flattened.  With  some  care  the  finger  can  be  passed  in  front 
of  the  cervix  and  somewhat  laterally,  in  which  movement  of  the  finger 
the  forward  limits  of  the  tumor  are  detected,  blending  w'ith  the  cervical 
wall  so  closely  that  the  margins  of  the  latter  are  defined  with  difficulty. 
With  the  posterior  margins  of  the  cervix  the  tumor  is  blended  in  a 
peculiarly  deceptive  way,  very  much  as  the  posterior  cervical  wall  dis- 
apjiears  in  the  uterine  body  in  retroversion  of  the  gravid  uterus.  At 
first  the  mass  is  soft,  with  a  sense  of  elastic  fluctuation.  After  two  or 
three  days  it  becomes  firmer  and  more  tense,  or  quite  solid,  caused  by 
advancing  coagulation  and  inflammation  with  plastic  affusion,  Avhich 
more  securely  walls  in  the  mass. 

In  these  large  effusions  the  uterus  can  be  defined  from  the  mass  only 
by  aid  of  the  sound.  It  is  needless  to  add  to  the  cautious  reader  that 
this  instrument  must  be  used  with  the  greatest  gentleness  and  care.  The 
way  is  first  cleared  by  emptying  the  bladder  with  the  catheter,  and  the 
sound  guided  by  the  fingers  forced  forward,  and  some  considerable 
manipulation  may  be  necessary.  The  curve  enters  forward  and  upward, 
and  the  point  may  be  felt  through  the  abdominal  wall  directly  over  the 
symphysis.  By  external  manipulation  the  uterus  may  be  felt  u]ion  the 
point  of  the  sound,  its  lateral  walls  defined,  and  the  tumor  moved  with- 
out imparting  any  motion  to  the  uterus.  This  shows  that  the  tumor  is 
unconnected  with  the  uterus.  Leaving  the  sound  in  the  uterine  cavity, 
the  finger  may  be  introduced  into  the  rectum,  where  it  detects  a 
rounded,  more  or  less  yielding  tumor,  to  which  no  movement  can  be 
imparted  by  manipulating  the  sound  within  the  uterus.     An  exam- 

VOL.  I. iS 


754  PELVIC  HEMATOCELE  AND  HEMATOMA. 

ination  carried  out  in  this  way  demonstrates  that  this  quickly-develop- 
ing tumor,  attended  with  pain,  shock,  and  anaemia,  is  not  uterine  or  an 
ovarian  tumor  or  a  fibroid,  as  nothing  will  give  this  rational  and  phys- 
ical symptom  but  a  pelvic  effusion  of  blood.  At  a  very  early  period 
it  may  be  impossible  to  make  this  careful  local  exploration,  as  the 
patient's  condition  will  not  permit  the  least  excitement;  and  if  this 
holds  true,  it  is  prudent  to  wait  several  days  befoj-e  undertaking  it, 
as  the  physician  will  find  enough  to  do  without  going  into  elaborate 
methods  of  examination. 

The  tumor  is  often  felt  through  the  vagina  before  it  is  above  the 
brim  of  the  pelvis.  The  extent  of  swelling  in  the  vagina  depends 
upon  the  depth  of  the  Douglas  space.  Voisin  states  that  early  in  the 
history  of  the  effusion  the  tumor  is  slightly  movable.  This  might 
hold  true  of  very  small  effusions  after  firm  coagulation  and  before  it 
is  enclosed  by  plastic  effusion.  It  is  a  doubtful  sign,  and  had  better 
not  be  relied  upon.  The  tumor  often  does  not  at  once  attain  its  max- 
imum size,  but  advances,  not  continuously,  but  by  a  series  of  starts 
which  correspond  with  the  menstrual  periods.  In  some  cases  a  small 
tumor  may  be  detected  in  front  of  the  large  tumor  just  above  the 
pubes,  which  is  the  uterus,  as  may  be  proven  by  the  employment  of 
the  sound.  The  hemorrhagic  tumor  varies  in  consistence  at  different 
parts,  fluctuating  in  one  region,  elastic  in  another,  or  soft  or  resistant 
at  another.  At  some  points  it  gives  the  sensation  of  a  solid  tumor, 
but  for  the  first  week  usually  the  tumor  over  its  general  surface  gives 
the  peculiar  feel  of  a  blood-clot  (Poncet). 

In  Poncet's  monograph  Bouchacourt  is  stated  to  have  observed 
bloody  urine.  In  some  cases  the  tumor  has  pressed  upon  the  ureters, 
throwing  the  urine  back  upon  the  kidneys,  causing  uraemia,  with  fatal 
results.  The  pressure  exerted  by  the  mass  upon  the  lumbar  or  sacral 
plexus  of  nerves  causes  severe  neuralgia  within  the  limits  of  these 
nervous  areas.  Under  some  circumstances  the  tumor  compresses  the 
large  venous  trunks  and  causes  oedema  of  the  lower  extremities,  being 
greater  upon  that  side  which  corresponds  to  the  greatest  bulk  of  the 
mass.  Cases  of  phlebitis  of  the  side  exposed  to  greatest  pressure  have 
been  also  noted,  in  some  instances  too  early  for  the  condition  to  be  due 
to  blood-poisoning ;  or  possibly  one  ought  to  say,  rather,  that  no  evi- 
dence of  blood-poisoning  other  than  this  had  appeared.  And  in  other 
instances  traces  of  general  infection  developed  long  afterward.  It  is 
difficult  to  regard  the  phlebitis  as  due  simply  to  pressure,  unless,  as  we 
have  noted  above,  it  is  the  sudden  development  of  the  mass,  which 
causes  its  presence  to  be  so  much  more  actively  resented  by  the  near 
parts  than  is  usually  the  case  in  pelvic  tumors  of  more  gradual  devel- 
opment. Extensive  oedema  of  the  vulva  and  vagina  has  been  noted 
and  explained  as  due  to  the  pressure.     In  an  instance  of  oedema  of 


ll.KMATOCF.U:.  7.-,.-, 

(lie  \;ii:iii;i  tlic  purl  (oi'iiicd  ;i  sort  ol"  cii.-liiini  wliidi  prujtctrd  ((trward 
bctwcfii  the  l:il)i:i.  'i'lic  latlcr  is  a  foiiiinon  fcatiii'c  that  attends  lame 
(.'ll'iisious,  and  is  assut'iatcd  with  a-deinu  ot"  the  i-xtreniity ;  hut  the 
phlegmasia  dolens  is  rare,  hut  two  cases  observed  by  iSIadj^e  and  one 
by  IJerniitz  havini^  been  n(»tiee<L 

In  the  nietrorrhajiie  hicniatoeele  a  ihtu  oi"  bhiod  is  noticed  externally 
from  the  vagina  durinj^  the  attack,  'J'he  peritonitis  is  very  slight  as  a 
rule,  and  a  eaeheetie  appearance  rapidly  develoj)s.  The  periodic  exac- 
erbations so  marked  in  the  menstrual  variety  are  absent.  Another 
feature  of  this  form  is  a  frequently-recurring  metrorrhagia  a  few 
hours  or  days  after  the  attack,  and  continuing  until  al)sorption  of  the 
pelvic  eti'usion.  This  variety  is  quite  prone  to  be  attended  with  nausea 
and  vomiting.  Snow  Beck  notes  an  instance  of  marked  exception  to  the 
rule  in  which  the  j)ain  ceased  on  the  appearance  of  the  tumor,  or,  as  he 
ought  to  have  said,  when  coagulation  of  the  effused  blood  was  complete. 

In  the  cataclysmic  cases  of  Barnes  only  that  portion  of  the  blood 
settling  in  the  pelvic  cavity  coagulates,  and  that  imperfectly.  Peri- 
tonitis does  not  take  place ;  the  l)lood  does  not  therefore  become 
encysted,  and  thus  no  tumor  forms.  Collapse  and  death  intervene 
too  quickly  for  the  usual  train  of  symptoms  to  form.  Notwithstand- 
ing the  fact  that  the  loss  of  blood  is  the  cause  of  death — in  fact,  may 
be  called  the  disease  itself — yet  the  most  active  feature  of  the  attack 
is  the  great  preponderance  of  shock  over  anaemia. 

The  symptoms  of  pelvic  hsematocele  due  to  cachexia  are  the  more 
gradual  advance  of  the  haematic  accumulation,  the  pain  gradually  gain- 
ing intensity,  a  lowering  of  the  temperature  partly  due  to  blood- loss  and 
in  part  to  shock.  A  well-defined  pelvic  tumor  is  in  some  cases  absent, 
especially  in  a  lowered  and  vitiated  state.  A  fatal  ending  is  common. 
Pelvic  haematocele  attending  typhoid  fever  is  needless  to  refer  to,  as 
the  accident  is  necessarily  fatal. 

The  course  and  termination  of  a  pelvic  haematocele  are  very  uncer- 
tain factors,  in  our  estimation,  of  the  disease.  While  it  may  be  said 
that  hematocele,  except  in  most  severe  forms,  always  terminates  with- 
out destroying  life,  yet  it  is  very  difficult  to  estimate  to  what  extent  the 
subject's  future  may  be  affected.  As  the  local  condition  advances  to  a 
favorable  termination,  the  tumor  grows  smaller  and  firmer.  This  is  the 
first  act  in  the  absorptive  process.  In  twentA--four  cases  observed  by 
Carl  Braun  absorption  was  complete  in  fi-om  two  to  six  months.  In 
twenty-five  cases  noted  by  Voisiu  fifteen  terminated  in  absorption.  Bandl 
noted  the  following  periods  in  which  this  termination  was  completed  : 

In  2  oases  in  \l  months. 
In  .1     "      "   -1"       " 
In  1  case    "  6         " 
In  1     "      "8 


756  PELVIC  HEMATOCELE  AND  HEMATOMA. 

In  whatever  way  health  is  restored,  the  process  is  a  slow  one.  The 
progress  toward  recovery  is  subject  to  so  many  interruptions,  owing  to 
the  intimate  relations  of  the  tumor  to  the  menstrual  function,  that 
the  natural  termination  is  indefinitely  prolonged.  In  some  instances 
no  marked  change  occurs  after  several  years,  the  tumor  maintaining  its 
same  relative  size  and  density.  Delore  has  recorded  a  case  that  pre- 
sented the  same  appearance  for  five  years.  Such  a  case  is  exceptional 
(Poncet).  Dr.  Barnes  says  that  many  cases  supposed  to  terminate  by 
absorption  gradually  diminish  in  size  as  their  contents  escape  through 
a  small  opening,  but  so  slowly  as  to  elude  notice.  In  the  minor  forms 
of  hsematocele,  with  a  moderate  eifusion,  in  some  cases  so  small  as 
almost  to  escape  notice,  and  with  all  the  general  symptoms  moderate  to 
a  like  extent,  absorption  is  the  rule,  and  in  a  few  days,  or  at  most  a 
few  weeks,  the  mass  disappears  as  quietly  as  it  came.  Barnes  asserts 
that  these  cases  are  very  common ;  but  if  so,  their  true  nature  is  not 
yet  commonly  understood  by  medical  men.  We  may  know  when  a 
hematic  tumor  of  the  pelvis  is  terminating  by  absorption,  as  the  mass 
grows  smaller  and  firmer  to  the  touch.  The  latter  sign  is  a  point  in 
spontaneous  absorption,  for  if  the  tumor  becomes  soft  and  fluctuating  it 
indicates  that  the  contents  are  breaking  down  and  it  is  seeking  an 
external  opening.  The  amount  of  extravasation,  the  age,  and  the  gen- 
eral condition  of  the  subject  are  the  circumstances  that  modify  the 
duration  of  the  absorption  process.  Poncet  states  that  when  the  mass 
has  kindly  relations  with  the  menstrual  function,  resolution  advances 
by  successive  amendments  coincident  with  menstrual  epochs,  and  conse- 
quently having  a  duration  of  several  months.  He  is  emphatic  in  the 
opinion  that  termination  in  health  is  the  rule,  especially  when  all  sur- 
gical treatment  is  abstained  from. 

When  the  contents  of  the  hseraatocele  escape  externally,  the  outlet  is 
formed  by  ulceration  of  the  cyst-wall  outward,  by  the  rectum,  by  the 
vao-ina,  or  through  the  encapsulating  membrane  into  the  abdominal 
cavity.  Bandl  states  that  the  most  frequent  exit  is  into  the  rectum. 
In  twenty-seven  cases  Voisin  noticed  escape  into  the  rectum  six  times, 
and  in  a  like  number  of  cases  it  gained  an  outlet  by  the  vagina  in  three. 
Escape  into  the  peritoneal  cavity  is  alwavs  a  fatal  channel  of  exit,  and 
fortunately  occurs  but  rarely.  Escape  by  the  rectum  is  liable  to  be 
attended  with  dangerous  result.  Fecal  matter  may  find  entrance  into 
the  sac  of  the  haematocele,  and  gas  from  the  rectum  is  quite  sure  to. 
The  consequence  is  rapid  changes  in  the  contents  of  the  cyst  with 
quickly-developing  evidences  of  blood-poisoning.  The  fetor  generated 
in  the  cyst  under  these  circumstances  is  sui  generis.  Septic  intoxication, 
is  rare  after  opening  by  the  vagina,  but  the  vaginal  walls  offer  greater 
resistance  to  the  ulcerative  process  than  those  of  the  rectum.  Some- 
times a  double  perforation  by  rectum  and  vagina  is  met  with,  and  rare 


HJEMATocr.Li-:.  757 

cnscs  arc  on  i-ccocd  in  wliicli  triple  (ij)('iiiiijj,s  occui'ixil,  by  rceluiu,  va<;iiia, 
and  alulniiiiiial  wall.  Instead  ol"  <;ainin}>;  exit  (jiiictly  by  tin;  rcctinn,  a 
sort  of  crisis  is  observed.  Tlic  pain  becomes  severe,  exaspei'atcd  by 
prcs'^nre  or  movement,  chills  with  niarUcd  liiuli  temperature,  vomitinji:, 
si<in  dry,  pulse  small  and  fVc(pient,  with  ccili*-  and  t(!iicsnuis.  Ai"tcr 
some  days,  and  lullowino-  an  abnndant  diarrh(ca,  tliei'c  is  a  jrcneral  and 
sudilen  amendment,  attended  by  escape  oC  black  and  olTcnsive  disehart^e 
by  the  rectum.  'I'liere  is  at  once  a  ra])id  diminiiiion  in  the  size  of  the 
abdomen,  but  the  tumor,  instead  of  entirely  (lisa|)pearinu-,  residts  in  a 
small  induratiou  Avhicii  persists  indetiuitely.  A  (quantity  of  fluid  as 
large  as  four  quarts  has  been   known  to  escape  by  the  anus. 

The  dcijeneratiou  of  cyst  contents  into  pus  is  an  infre([uent  termina- 
tion, and  attended  with  alarming  symptoms.  Chills,  fever,  dry  skin, 
rapid  and  shrinking  pulse,  severe  pain  in  the  loins  extending  to  the 
Ws,  are  the  most  marked  evidences  of  this  dano-erous  chancre.  The 
symptoms  resemble  those  of  perforation  of  the  cyst  into  the  abdominal 
cavity,  but  ai'e  of  longer  duration.  When  the  cyst  contents  find  their 
way  into  the  peritoneal  cavity  the  termination  is  nearly  certain  death. 
AV'lien  death  results  in  the  usual  course  of  the  disease,  it  is  caused  by 
wearing  the  patient  out.  Profound  alterations  of  nutrition,  prostrating 
high  temperature,  exhaustion,  death,  are  the  fatal  chain  of  events. 

Diagnosis. — The  positive  recognition  of  pelvic  hematocele  at  its 
various  stages  offers  one  of  the  great  problems  of  pelvic  diagnosis.  It 
is  sometimes  very  easy  and  at  others  exceedingly  difficult.  The  period 
at  which  the  disease  is  brought  under  observation  has  much  to  do  with 
its  easy  recognition.  Dolbeau  says  that  while  pelvic  hematocele  is  not 
the  only  pelvic  disease  that  begins  suddenly,  fever,  sudden  and  severe 
pain,  and  abdominal  distension  may  occur  in  pelvic  peritonitis  and  in 
intense  ovarian  congestion.  Pelvic  hiTematocele  is  never  ushered  in 
with  fever,  nor  is  ovarian  congestion  :  to  guard  against  error  he  trusts 
to  one  unfailing  sign — namely,  the  direction  in  which  the  cervix  is  dis- 
placed forward  behind  the  symphysis. 

Intraperitoneal  effusion  makes  its  appearance  without  premonitoiy 
signs,  and  in  general  terms  the  symptoms  are  those  which  characterize 
hemorrhage.  In  the  menstrual  group  there  is  defect  in  menstrual 
excretion  which  precedes  the  outbreak  ;  and  in  the  hemorrhagic  group 
there  is  a  profuse  discharge  of  blood  from  the  genitals  before  and  dur- 
ing the  act  of  intraperitoneal  effusion.  In  the  first  there  is  severe  ]ieri- 
tonitis  with  less  anaemia  and  prostration,  and  in  the  second  less  peri- 
tonitis with  greater  prostration  and  evidences  of  hemorrhage.  The 
degree  of  collapse  in  ha?raatocele  is  quite  out  of  proportion  to  the 
amount  of  blood  lost,  as  a  rule.  In  the  hematocele  of  menstrual 
retention  there  is  what  one  may  call  the  secondary  shock,  due  to  the 
quickly  supervening  peritonitis.     In  rupture  of  the  ovary  the  effusion 


758  PELVIC  HJEMATOCELE  AND  HuEMATOMA. 

is  sudden  and  profuse;  the  rupture  of  ovarian  varix  is  improbable 
when  there  are  no  signs  of  venous  stasis  in  the  lower  extremities, 
and  especially  on  the  external  genitals,  either  past  or  present. 

In  case  of  small  ovarian  tumors  yet  in  the  pelvis  suddenly  taking  on 
inflammatory  action,  the  pain  is  sudden  and  severe,  the  cyst  not  mova- 
ble, with  rectal  or  bladder  symptoms.  The  diagnosis  is  made  yet  more 
difficult  by  pelvic  effusion  being  sometimes  one-sided  and  cyst-like,  as 
in  a  specimen  exhibited  by  Phillips  at  the  London  Obstetrical  Society 
(1868).  It  is  safe  to  say  in  ordinary  cases  that  the  ovarian  cyst  dis- 
places the  uterus  to  one  side,  while  the  hsematocele  forces  the  uterus  for- 
ward without  obliquity.  Expectation  would  clear  up  the  atmosphere 
of  doubt  that  obscures  this  condition,  or  a  careful  aspiration  would  at 
once  expose  the  character  of  the  retro-uterine  mass.  In  the  case  of 
small  ovarian  tumors  becoming  ruptured,  Winckel  makes  the  point 
that  while  the  pain  and  collapse  would  resemble  that  of  hsematocele, 
the  cyst  contents  would  diffuse  themselves  and  the  tumor  grow  smaller 
and  softer,  notwithstanding  the  peritonitis,  while  the  haematic  tumor 
would  grow  larger  and  firmer.  Ovarian  tumors  occupying  Douglas's 
space  present  a  history  of  considerable  duration,  have  uniform  density 
of  surface,  fluctuate  on  palpation,  with  no  peritonitis  or  variation  in 
volume  as  in  hsematocele.  The  symptoms  of  compression  of  rectum 
and  bladder  gradually  intensify  in  the  cyst,  but  in  hsematocele  these 
symptoms  present  themselves  early  and  gradually  abate.  Between  an 
incarcerated,  inflamed  retro-uterine  cyst  and  a  hsematocele  with  a  like 
history  and  symptoms,  the  difficulties  of  differentiation  are  sometimes 
insuperable.  Nothing  but  aspiration  with  a  small  needle  can  prove  the 
difference.     McCormick  gives  an  instance  in  which  even  this  failed. 

A  retroflexion  of  a  gravid  uterus  at  three  months  is  very  difficult  to 
distinguish  from  a  retro-uterine  hgematocele.  A  hseraatocele  has,  in  fact, 
been  so  mistaken  in  several  instances.  In  the  gravid  uterus  there  are 
softening  'of  the  neck,  absence  of  menstruation,  the  characteristic  dis- 
coloration of  cervix  and  vagina,  a  smooth,  uniform,  and  elastic  tumor, 
giving  consistency  of  surface  at  all  points,  with  marked  line  of  flexion 
between  the  cervix  uteri  and  body.  Pain  in  this  condition  is  functional 
and  due  to  disturbance  of  near  parts.  Contrast  with  this  a  tumor  of 
uneven  surface,  with  points  of  varying  consistency,  the  peculiar  dis- 
placement of  the  uterine  cervix,  and  absence  of  the  flexion  line,  while 
the  pain  of  hsematocele  is  persistent,  with  the  tumor  itself  as  a  point 
of  radiation.  A  very  difficult  problem  to  solve  is  presented  in  this 
case,  and  if  an  anaesthetic  affords  any  advantage  it  ought  to  be  employed. 
Expectancy  furnishes  a  clue  to  the  real  nature  of  the  pelvic  disturbance. 
In  hsematocele  the  tumor  shows  a  disposition  to  shrink  and  the  pain  to 
abate;  in  retroflexion  of  the  gravid  uterus  the  tumor  grows  firmer, 
larger,  with  an  increase  of  functional  disturbance  of  near  parts. 


lI.KMATOCKLi:.  75!) 

(lallartl  says  llial  Wf  may  .-I'ai'cli  in  \aiii  lnr  dillliNiiiial  si^ns 
lu'twccn  I'Xti-a-iitci-inc  |»r('iiiiaii<'y  and  lia'nialocclc.  ll  is  well  to 
notice  what  l"f\v  we  liavr.  TIk'  Ininor  of  cxtfa-iilci'inc  I'o'iMiion  is 
rare  in  the  rctro-ntcrinc  space;  li;enialoeek'  is  <'oniinon.  In  llielirst 
tlie  tumor  is  of  slow  growth,  willi  the  rational  si<;iis  of  pre^naiicv — 
iu'tal  movonieiits,  breast-chaniros,  anienorrha'a,  soinotinu's  meiioi-rha- 
ui;i,  hut  not  metrorrhagia  as  in  hscmatocele.  If  not  called  in  until  the 
rupture  of  the  i'a^tal  sac,  it  is  douhtfid  if  a  dilVeivntial  (lia<i;nosis  can  be 
inacK'.  If  one  had  a  chance  to  deliberately  study  the  case  before  the 
catastroi)he  of  rupture,  it  is  probable  that  a  mistake  wduld  not  be 
made. 

In  a  paper  on  perimetritis  by  J)r.  John  Williams  in  the  London 
Obstetrical  Society,  Dr.  Graily  Hewitt  said  that  it  and  ha3matocele 
were  very  ditticult  to  distino-uish.  At  the  outbreak  of  the  attack  the 
local  conditions  afford  but  little  evidence  of  value.  Both  diseases  are 
attended  with  rapid  accumulations  in  the  Douglas  space — in  the  one 
with  chill  at  the  opening  of  the  attack  usually,  inflammation  always; 
and  in  hematocele  we  have  shock.  In  pelvic  peritonitis  the  chill  is 
the  beginning  of  a  continued  fever,  while  in  hsematocele  it  is  frequently- 
repeated.  In  the  latter  the  pelvic  mass  antedates  the  chill,  and  in  the 
former  the  chill  precedes  the  pelvic  tumor.  In  cellulitis  the  tumor 
presents  itself  slowly,  and  is  not  severe  or  sudden,  and  is  usually  sit- 
uated to  one  side  in  the  broad  ligament,  and  the  tumor  is  not  so  large 
as  in  hfematocele ;  further,  the  board-like  induration  of  cellulitis  is  not 
detected  in  the  hsematic  tumor.  If  the  attack  follows  labor  or  abortion, 
the  evidence  will  favor  pelvic  peritonitis.  If  the  symptoms  begin 
during  menstruation,  and  the  discharge  suddenly  stops,  and  the  ces- 
sation is  coincident  with  pain,  attended  with  chill,  followed  by  fever,  it 
is  jirobably  peritonitis.  If  menstruation  w'ere  due,  but  did  not  appear, 
but  sudden  and  severe  pain  came  on  with  collapse,  it  is  more  likely  to 
be  liiematocele.  If  the  attack  is  not  associated  with  delivery  or  abor- 
tion, the  diagnosis  inclines  more  to  hrematocele  than  to  pelvic  peritoni- 
tis or  cellulitis.  The  mistake  of  confounding  a  periuterine  phlegmon 
with  hfematocele  might  easily  be  made,  but  the  remarks  already  made 
would  apply. 

Dr.  Rasch  states  that  there  is  low  tem]->erature  for  twenty-four  hours 
after  an  attack  of  hfematoeelc — 96°  to  97°  F. — and  the  uterus  is  more 
movable  than  in  cellulitis. 

In  cases  of  adeno-lym])hangitis  in  the  post-pubic  region,  mentioned 
by  Guerin,  the  mass  is  well  defined  by  the  double  touch,  and  is  small 
and  nodular.  The  small  tumors  attending  this  disease  posterior  to  the 
cerxnx  could  hardlv  be  mistaken  for  a  hoematocele. 

Dr.  Smyly  has  detected  urobilin  in  the  urine  in  cases  of  pe]\-ic  lurma- 
tocele,  and  gives  it  diagnostic  value.     When  the  urine  is  alkaline,  the 


760  PELVIC  HuEMATOCELE  AND   HEMATOMA. 

pigment  has  the  usual  color ;  and  when  acid,  it  is  red.  A  drop  of  zinc 
chloride  in  an  ammoniacal  solution  shows  the  characteristic  green 
fluorescence.  In  the  spectrum  a  band  between  the  green  and  blue 
absorption-lines  is  observed  to  attend  the  presence  of  urobilin.  Urine 
containing  the  pigment  has  a  clear  to  a  dull-brown  color.  Dr.  Wilt- 
sliire  has  noticed  that  cases  of  hsematocele  were  attended  by  a  peculiar 
jaundice,  which  is  symptomatic  and  due  to  the  absorption  of  the  biliary 
coloring  matter  of  blood  when  the  effusion  is  large. 

Bernutz  formulates  the  following  as  a  guide  to  the  diagnosis  of  ova- 
rian hsematocele :  "  There  is  absence  of  menstruation  or  of  any  bloody 
discharge  from  the  vulva  at  the  time  the  symptoms  developed ;  the 
coexistence  at  the  commencement  of  the  attack  of  two  distinct  groups 
of  symptoms — one  referable  to  internal  hemorrhage,  the  other  to  inflam- 
mation of  the  peritoneum  ;  lastly,  the  absence  of  dysmenorrhoea  at  the 
time  or  at  the  preceding  menstrual  period.  Such  a  concurrence  of 
symptoms  is  strongly  confirmatory  of  ovarian  lesion."  In  explanation 
of  the  above  it  may  be  proper  to  say  that  the  absence  of  dysmenorrhoea 
demonstrates  that  no  retention  existed,  and  the  absence  of  blood-dis- 
charge from  the  vulva  shows  that  menstruation  was  not  present. 

The  diagnosis  between  menstrual  retention  and  hsematocele  depends 
on  the  relation  of  menstrual  pain  to  the  tumor.  The  pain  in  metror- 
rhagia occurs  considerably  before  or  at  the  discharge,  while  the  periodic 
pain  in  menstrual  retention  occurs  in  the  absence  of  discharge,  with 
coincident  distension  of  the  pelvic  tumor — a  condition  never  observed 
in  the  tumor  of  metrorrhagic  hsematocele.  The  periodic  increase  of  size 
in  the  menstrual  hsematocele  is  always  attended  by  discharge  from  the 
vulva.  Equally  so  in  hsematoceles  from  menstrual  defect  the  effusion 
is  preceded  by  absence  of  menstruation. 

The  diagnosis  between  sources  of  hemorrhage  has  been  regarded  as 
impossible.  In  rupture  of  the  tube  from  over-distension  and  hsema- 
tocele from  menstrual  retention  the  following  doubtful  distinction  may 
be  made :  distension  of  the  tube  is  a  gradual  process,  and  one  attended 
at  no  stage  by  pain,  while  dysmenorrhoea  is  a  leading  trait  of  menstrual 
retention,  especially  the  month  previous  to  attack  (Bernutz). 

In  the  matter  of  the  minute  distinctions  enumerated  in  the  most 
difficult  field  of  diagnosis,  the  pelvis,  but  little  has  been  said  about  the 
history  afforded  by  the  patient.  This  is  indeed  the  medium  through 
which  all  the  objective  and  subjective  symptoms  have  to  be  viewed. 
Without  this  element  in  the  study  of  a  case  no  local  exploration  can  be 
relied  upon  to  furnish  differences  broad  enough  to  rest  a  positive  opin- 
ion upon.  This  remark  is  made  in  this  connection  because  it  applies 
with  peculiar  force  to  the  differentiation  of  menstrual  and  metrorrhagic 
hsematoceles  from  the  deposits  of  inflammatory  origin  peculiar  to  the 
female  pelvis. 


HA'JMA  TOVKLK.  70  I 

IkiikII  iiiciif ions  the  (icciiirciicc  of  l:iltr:il  li:i'iii:i(<)iii(tr:i  in  (liiplicalc 
Uterus.  riu'  (Ic'i'p  and  lateral  relations  ol'  the  niitss,  tiji;  periodie  pain, 
the  monthly  increase  and  snpervenin<;-  deerea.se  in  size,  the  absence  of 
fever  and  peritoneal  inHaniniatorv  symptoms,  p(jint  to  a  dilTicnltv  other 
tlian  hiematocele.  The  early  aji;e,  a  period  nearly  cxenij)!  IVorn  h;i  nia- 
toeele,  «:;ives  additional  <2;roiinds  for  distinction. 

It  is  hardly  possible  that  a  iihroid  uterine  tumor  can  he  mistaken  for 
hjomatocele,  hut  Gusserow  has  ^iven  some  traits  of  th(!  latter  in  this 
relation  that  may  be  worth  meutioning.  In  fibroma  the  tumor  is  lim- 
ited on  all  sides,  uniform  density,  its  mobility  more  or  less,  but  clearly 
related  to  the  uterus,  absence  of  peritoneal  tenderness  in  isolated  fibrf)ma 
— none  of  mIucIi  characteristics  belong  to  hsDmatocele,  Mhich  shows  a 
tendency  to  ditfuse  itself,  to  dissect,  as  it  were,  into  the  surrounding  ti.s- 
sue,  whicJi  is  sometimes  observed  in  a  marked  degree  on  the  vaginal 
wall. 

Hart  and  Barbour  assume  in  their  diagnosis  that  inflammatory  adhe- 
sions occur  previous  to  the  effusion.  They  say  :  "  It  is  often  said  that 
effused  blood  naturally  gravitates  into  Douglas's  space.  It  is  not  so. 
It  is  there  because  it  is  affused  near  it  and  causes  Douglas's  pouc^h  to 
bulge  only  w'lien  it  is  affiised  beloM'  adhesions  which  prevent  its  spread- 
ing." AVhen  in  any  given  case,  as  above,  on  vaginal  examination  a 
firm  convex  tumor  is  felt,  and  the  cervix  so  closely  pressed  behind  the 
symphysis  as  to  be  almost  inaccessible,  and  by  the  bimanual  exam- 
ination the  uterine  fundus  is  distinctly  felt  just  below  the  abdomi- 
nal Avail,  and  generally  to  one  side,  we  have  a  condition  of  affairs  that, 
in  connection  w' ith  its  histoiy,  establishes  the  existence  of  a  pelvic  effu- 
sion. Meadows  gives  great  importance  to  the  vaginal  tumor  coincident 
with  the  attack,  as  no  mass  can  be  produced  so  rapidly  with  such  symp- 
toms from  other  causes.  The  idea  that  a  pelvic  blood-collection  gives 
no  evidence  of  tumor  prior  to  coagulation  must  be  admitted  ;  but  Hart 
and  Barlwur,  in  order  to  be  consistent  with  their  opinion,  as  mentioned 
above,  of  antecedent  adhesions,  assert  that  a  hemorrhagic  accumulation 
in  the  pelvis  gives  no  physical  signs  more  palpable  than  flatus  or 
ascites  unless  enclosed,  and  these  can  be  recognized  only  by  puncture 
or   aspiration. 

It  must  be  rare  that  a  cancer  of  the  pelvic  organs  would  give 
occasion  to  a  mistake  in  diagnosis;  but  Gallard  gives  one  case  in  which 
hsematocele  was  believed  to  exist,  but  which  on  post-mortem  examina- 
tion turned  out  to  be  a  cancer  htematodes  of  the  ovary  which  occupied 
a  position  behind  the  uterus.  ]\Iarrotte  recorded  a  case  in  which  an 
accumulation  of  feces  gave  cause  to  suspect  a  hsematocele.  A  purga- 
tive cleared  up  the  doubt. 

The -same  difficulties  that  attend  the  diagnosis  of  hsematocele  follow 
us  in  an  examination  of  haematoraa.     Hart  and  Barbour  sav  that  when 


762  PELVIC  HjEMATOCELE  AND  HEMATOMA. 

the  eifiision  is  in  the  broad  ligament  it  is  difficnlt  to  recognize,  and 
is  usually  found  on  post-mortem  examination.  The  physical  signs  in 
typical  cases  differ  in  essential  points  from  those  of  hsematocele.  The 
tumor  occurs  suddenly,  with  absence  of  inflammation  for  a  longer  period 
than  in  the  intraperitoneal  effusion.  The  tumor  is  not  in  the  pouch  of 
Douglas,  but  bulges  around  the  uterus.  The  hsematoma  is  especially 
liable  to  be  mistaken  for  a  cellulitic  deposit.  The  situation  of  the  ute- 
rus in  the  two  classes  of  effusions  gives  but  little  evidence.  When  the 
uterus  is  forced  above  the  pubes  it  is  probable  that  the  blood  is  extra- 
peritoneal, and  is  effused  between  the  folds  of  the  broad  ligament,  which 
usually  displaces  the  organ  in  the  direction  named  (Madge).  Unilat- 
eral hsematoma  is  more  frequent  upon  the  left  side,  and  in  such  a  case 
the  uterus  is  displaced  laterally  and  appears  to  rest  upon  the  tumor, 
while  in  hematocele  the  mass  displaces  the  uterus  upward  and  forward 
in  the  retro-uterine  and  downward  and  backward  in  the  anteuterine 
groups.  The  uterus  is  more  mobile  in  hsematoma,  which  is  probably 
due  to  the  fact  that  peritonitis  is  less  quickly  developed,  and  not  so 
severe  as  in  the  intraperitoneal  effusions.  Tait  says  that  if  the  febrile 
symptoms  have  set  in  and  the  clot  broken  clown,  the  diagnosis  is  mere 
guesswork,  and  any  operative  interference  hardly  justifiable.  The  fol- 
lowing manipulation  is  suggested  by  Frankenhauser  and  followed  by 
Bandl :  Before  the  blood  is  encapsulated — and  we  ought  also  to  say 
before  it  is  coagulated — if  the  patient  is  placed  in  the  knee-chest  posi- 
tion the  blood  will  flow  out  of  the  Douglas  space,  and  return  again  to 
the  pelvis  when  the  patient  assumes  the  dorsal  posture.  In  hsematoma 
the  tumor  must  keep  its  situation  and  form,  no  matter  what  position 
the  patient  may  be  in.  Early  in  the  attack — and  it  must  be  practised 
early  to  be  of  any  value — when  the  patient  is  suffering  pain  and  col- 
lapse, it  must  be  difficult  to  practise  this  manipulation.  If  Hart  and 
Barbour's  theory  is  correct  also  in  regard  to  the  antecedent  adhesions  in 
Douglas's  space  being  the  cause  of  the  hsematic  tumor  in  this  region, 
the  posture  test  would  prove  useless.  This  remark  is  thrown  in  for  the 
benefit  of  the  younger  readers,  in  order  to  show  the  difficulties  in  har- 
monizing the  conflicting  statements  of  authors. 

The  form  of  the  tumor  may'be  to  a  certain  extent  a  diagnostic  sign 
of  hsematoma.  If  a  tumor  lateral  to  the  uterus  is  quickly  developed 
and  connected  with  the  uterus  by  an  isthmus,  it  is  probably  in  the 
broad  ligament  and  extraperitoneal.  It  may  be  that  there  are  two 
tumors  laterally  situated  on  the  same  level  and  connected  by  an  isth- 
mus :  this  condition  is  characteristic  of  hsematoma.  The  surface  of 
the  tumor  also  affords  evidence.  In  hsematoma  it  is  uneven,  knobbed, 
and  rough,  owing  to  the  unequal  cellular  spaces  filled  with  blood.  This 
is  especially  true  of  the  lower  surface  of  the  tumor  situated  deep  in  the 
vagina.     In  hsematocele  the  lower  (vaginal)  surface  of  the  tumor  is 


JLEMATOCIJLK 


lii-.i 


smootli.  Tlic  al)(l<»iniii:il  siirliicc  of  tlir  lia'iiuiloina  is  >li:ir|tl\-  (l<-rui((l  ; 
in  liieinalocclc  it  is  ditliised  from  \Vfl(Iin<»;  tojj^ctluT  ol"  .suiTouiiding 
parts.  The  fact  just  spoken  of,  tlii'  vaginal  prolongation  of  tlic 
tumor,  is  vci-y  characteristic  of  lucmatoma.  In  lueniatocclc  the  tuiiMjr 
cannot  invatle  the  vagina  farther  than  tlie  extent  to  which  Doughis's 
j)ouch  descends  heh)\v  the  uterus,  Jt  is  true  that  this  varies  gr<'atlv  in 
indivichials,  l)ut  the  bulging  of  the  vaginal  wall  in  hiematoma  is  more 
usually  lound  lateral  or  antero-latcral ;  and,  fiu'ther,  in  ha^inatonia  the 
vaginal  tumor  gives  the  peculiar  feel  of  having  dissected  its  wav  into 
the  cellular  spaces  of  the  part. 

The  following  table  of  ditterential  diagnosis  is  condensed  from  Courtv, 
and  may  j)rove  of  value  to  the  reader: 


Phlegmon  of  the  Broad  Ligament  and 
Suppurative  Periton  it  is. 

Connected  with  delivery,  abortion,  or 
inflammaiion  of  pelvic  organs. 

Phlegmon,  a  tumor  of  moderate  size, 
not  displacing  cervix,  often  at  the  side, 
formed  after  the  commencement  of 
symptoms,  hard  at  first  and  very  sen- 
sitive, gradually  softening  and  becom- 
ing fluctuating. 

Pelvic  peritonitis  rises  above  the 
brim,  not  displacing  the  fixed  uterus 
to  any  great  extent. 

General  symptoms  continuing  till  the 
pus  gains  an  outlet. 

Extra-uterine  Pregnancy. 

Develops  slowly. 

At  first  no  functional  disorder  (?) : 
afterward  those  of  normal  pregnancy. 

Foetal  sounds  and  movements. 

Sometimes  amenorrha?a,  at  others 
regular  menstruation,  but  no  metror- 
rhagia. 

Retroflexion  and  Retroversion. 

"When  non-gravid :  slow  develop- 
ment, no  diminution  in  size. 

When  gravid :  symptoms  of  preg- 
nancy. 

Fibroid  Tumor. 

Development  slow  and  continuous. 
Sometimes  occur  at  menopause. 


Hcematocele. 

Unconnected  with  any  of  these  con- 
ditions, and  manifested  at  other  peri- 
ods than  those  of  delivery. 

Large  tumor  pushing  forward  the 
cervix,  behind  which  it  is  situated, 
formed  at  the  commencement  of  the 
disease,  soft  at  first,  not  sensitive,  hard- 
ening with  time,  and  losing  the  cha- 
racter of  fluctuating,  descending  to  the 
lowest  portion  of  Douglas's  space,  and 
displacing  the  fixed  uterus  to  a  great 
extent. 

General  symptoms  diminishing  after 
a  few  days,  long  before  the  disappear- 
ance of  the  tumor. 


Begins  suddenly. 

General  symptoms  more  or  less  seri- 
ous from  the  beginning. 

Auscultation  negative. 

Menstrual  disorders  coinciding  with 
metrorrhagia. 


Uterus  and  tumor  distinct. 


Development  rapid,  subsequent  dim- 
inution, always  in  period  of  sexual 
activitv. 


764 


PELVIC  HEMATOCELE  AND  HEMATOMA. 


Fibroid  Tumor  {continued). 
Amenorrhcea,  leucorrhcea,  or  metror- 
rbagia. 

Nodulations,  density  unequal. 
Softening  rare. 

Ovarian  Cysts. 
Develoj^ment  slow,  but  unlimited. 

No  symptomatic  disorders. 

Tumor  always  (?)  fluid  and  fluctu- 
ating. 

Hcp.matoma. 

Tumor  descending  into  recto-vaginal 
septum. 

Uterus  puslied  upward  and  forward, 
more  distinct  from  the  abdominal 
tumor. 

Violet  color  of  vaginal  cul-de-sac. 


Hcematocele  [continued). 
Menstruation  and  metrorrhagia. 

Regularity  of  outline,  equal  density. 
Softening  frequent. 


Rapid  development,  followed  by  de- 
crease. 

General  symptoms  more  or  less  se- 
rious. 

Tumor  at  first  fluctuating,  and  then 
hard. 


Tumor  higher  up,  projecting  at  the 
sides  and  behind  uterus. 

Uterus  fixed  in  varying  directions. 


No  disc'oloration  ;  frequent  paleness 
of  mucous  membranes.  ' 


In  conclusion,  we  may  quote  from  Hart  and  Barbour :  "  Hsematocele 
and  hsematoma  are  symptoms,  but  the  diagnoses  of  the  conditions  caus- 
ing the  hemorrhage,  unless  in  cases  of  extra-uterine  pregnancy,  are 
beyond  our  clinical  knowledge." 


Pelvic  Hematoma. 

Wherever  possible  in  our  study  of  hsematocele,  we  have  thrown  it 
into  contrast  in  all  its  relations  of  cause,  effect,  and  symptoms  with 
hsematoma.  The  field  has  thus  been  very  much  narrowed  in  all  that 
relates  to  the  unstudied  part  of  hsematoma.  So  important  are  the  dis- 
tinctions to  be  made  between  these  different  pelvic  conditions,  and  so 
frequently  are  they  confounded  by  authors  and  practitioners,  that  hem- 
atoma deserves  a  separate  study. 

Anatomy. — Blood  effused  within  the  pelvis,  but  external  to  the 
peritoneum,  takes  certain  directions  more  or  less  definite.  Tripier  has 
made  experiments  to  determine  the  resistance  of  the  peritoneum.  He 
first  injected  colored  fluid  into  the  broad  ligament  from  the  direction  of 
the  ovary.  A  pyramidal  tumor  was  formed  in  the  ligament  as  the  first 
result.  A  larger  quantity  of  fluid  with  greater  force  caused  an  exten- 
sion of  the  fluid  behind  the  rectum,  forcing  it  forward.  The  fluid  dis- 
colored the  mucous  membrane  of  the  vagina.  This  discoloration  of  the 
peritoneum  did  not  extend  beyond  the  junction  of  the  neck  with  the 
body  of  the  uterus,  and  that  organ  was  not  discolored.  When  the 
cauula  was  placed  at  the  posterior  border  of  the  broad  ligament,  the 


I'KLVIC  II.V.MATnMA.  7(j.j 

fluid  filled,  first,  the  V(  si<(>-iit(iin<'  riil-d<-.-;i<',  niid  sccoiully,  tlie  poste- 
ri»»r  ful-(U'-s;u',  both  .-ides  at  <iii<r.  Jlc  made  tlir  rcinarkablo  cxjHTi- 
lueiit  ol"  using  a  jUTs^^urc'  syringe  connected  with  a  manometer,  and 
mcasuroil  the  f'oi'ce  necessary  to  niptni'e  the  Itrnad  ligament  l)v  disten- 
sion. It  equalled  two  atmosj)lieres.  Poneet  exj)lains  this  gi-eat  .-tr(  nglh 
by  the  character  and  distrii)Uti(tn  ot"  the  connective  tis-ue  ot"  the  liga- 
ment. These  experiments,  further  than  testing  the  resistance  of  the 
peritoneum  and  the  channels  of  connection  through  the  connective-ti— 
sue  spaces  when  distended  hy  fluid  under  j)ressin-e,  prove  nothing.  'Jhe 
ditferenee  between  the  living  and  the  dead  subject  is  too  great,  ^\"e 
may  also  observe  that  the  fluid  in  Tripier's  ex})eriments  was  distributed 
in  a  manner  never  recorded  in  j)elvic  htematoma.  Beigel  verified  by 
post-mortem  examination  a  large  haematoina  in  the  folds  of  that  j)ortion 
of  the  broad  ligament  known  as  the  ala  vesj)erti]ionis.  The  subject 
died  from  pneiunonia,  and  tlie  discovery  of  the  hiematoma  was  acci- 
dental. Nona  says  that  the  effused  blood  is  generally  covered  by  false 
membrane,  but  this  is  not  so,  and  in  the  carefully-made  dissections  by 
Ball,  so  frequently  referred  to  by  Poneet,  no  covering  of  this  character 
"Was  observed. 

As  already  referred  to,  there  is  great  difference  of  opinion  as  to  the 
frequency  of  hiematoma.  Bandl  asserts  that  it  is  I'arely  met  with  out- 
side of  the  puerperal  condition.  All  those  who  follow  Bernutz  hold 
that  hiematocele  is  very  frequent  and  luTeniatoma  veiy  rare.  Tait  on 
his  individual  experience  believes  that  hsematoma  is  ten  or  twelve  times 
more  frequent  than  the  intraperitoneal  effusion. 

Causes. — Olshausen  relates  a  case  of  auteuterine  hiematoma  follow- 
ing acute  dysmenorrhoea.  The  anterior  lip  of  the  cervix  was  shortened, 
and  the  anterior  vaginal  vault  driven  backward  by  a  tumor  of  half-soft 
consistency.  ]\Iany  cases  of  htematoma  attend  forced  abortion  at  the 
€arly  weeks  and  rough  manipulation  in  gynecological  operations.  These 
cases  are  frequently  mistaken  for  cellulitis.  Careful  attention  to  the 
order  of  morbid  events  will  define  it  from  the  latter  condition.  In 
ha?matoma  the  local  lesion  precedes  pain  and  fever.  In  inflammatory 
deposits  fever  and  pain  are  preludes  to  the  development  of  the  jielvic 
mass.  Further,  the  induration  in  cellulitis  is  detected  in  regions  in 
"which  the  minor  forms  of  htematocele  are  rarely  observed.  AVe  find 
the  latter  developing,  as  it  were,  in  the  vaginal  wall,  forming  small, 
well-defined  masses,  usually  posterior  to  the  vaginal  portion,  rarely 
lateral,  with  a  slight  degree  of  uterine  immobility,  Avhile  cellulitis  is  dif- 
fused and  generally  lateral.  The  termination  is  the  same  in  both  cases, 
and  unless  the  distinction  is  made  early  it  may  l)e  difficult,  if  not  impos- 
sible, to  recognize  the  difference.  It  may  be  said  that  we  have  passed 
through  the  period  of  cellulitis  in  pelvic  pathology,  and  other  condi- 
tions will  now  come  to  the  front  that  were  formerlv  confounded  with  it. 


766  PELVIC  H^EMATOCELE  AND  HJEMATOMA. 

Diagnosis. — It  is  important  to  make  a  clear  diagnosis  between 
hsematocele  and  hematoma.  Both  are  sadden  in  their  development. 
If  the  patient  is  menstruating  at  the  time,  the  probabilities  favor  the 
catamenial  variety  of  hsematoma.  If  the  subject  has  not  menstruated 
for  eight  or  ten  Aveeks,  rupture  of  an  extra-uterine  foetal  sac  must  be 
considered.  If  menstruating  at  the  time  of  attack,  with  arrest  of  the 
flow  from  exposure  to  cold  or  chill,  it  is  probably  hsematoma.  The  symp- 
toms are  more  intense  in  intraperitoneal  than  in  extraperitoneal.  Tait 
says  that  he  never  saAV  anything  alarming  in  the  first  onset  of  the  latter 
form.  The  limitations  of  the  tumor  to  the  Douglas  space,  not  being 
felt  above  the  brim,  are  characteristic  of  hematocele.  When  beyond 
the  peritoneum  the  tumor  is  clearly  distinct  from  the  uterus,  but  closely 
connected  with  it,  is  felt  above  the  pelvic  brim,  and  is  soft  or  indis- 
tinctly fluctuating.  Examination  by  the  rectum  shows  that  the  tumor 
disappears  to  the  right  or  left  of  the  passage,  or,  in  other  words,  the 
tumor  is  sharply  defined.  Tait  says  that  he  has  seen  the  extraperitoneal 
effusion  (hematoma)  contain  pints  of  clots  and  reach  not  far  short  of 
the  umbilicus.  In  doubtful  cases  if  the  aspirator  is  used  and  pus 
escapes,  it  is  parametritis ;  and  if  blood-debris  and  pus,  it  is  a  suppura- 
ting hematoma.  The  diagnosis  is  very  difficult  when  small  blood-clots, 
form  within  the  folds  of  the  broad  ligaments. 

Prognosis. — In  the  case  of  the  small  clots  last  noted  above^  the  ter- 
mination is,  with  scarcely  an  exception,  favorable.  In  the  more  severe 
form  serious  differences  of  opinion  exist.  Poncet  claims  tliat  hsematoma 
is  more  grave  than  hematocele,  as  it  is  more  liable  to  rupture  the  peri- 
toneum, but  so  far  as  clinical  records  are  known  this  opinion  has  no  value. 
Kuhne  believes  the  outcome  is  favorable.  Bernutz  views  it  in  a  very 
serious  light.  Courty  states  that  the  periuterine  hematoma  generally 
terminates  in  recovery  by  absorption,  and  qualifies  his  opinion  by  the 
statement  that  the  outlook  is  not  so  favorable  as  in  hematocele,  as 
rupture  of  the  peritoneal  covering  and  escape  of  blood-clots  into  the 
abdominal  cavity  usually  cause  death.  Tait,  on  the  other  hand,  says 
that  the  hematoma  is  rarely  fatal,  while  the  intraperitoneal  is  generally 
fatal.  When  the  eff'usion  is  into  the  cellular  tissue,  the  natural  tendency 
is  toward  spontaneous  arrest ;  if  into  the  peritoneum,  the  hemorrhage 
is  excessive  and  irritation  of  the  peritoneum  very  great.  However,  out 
of  a  large  number  of  cases  Tait  never  saw  but  one  fatal.  It  is  undoubt- 
edly the  fact  that  the  more  generally  approved  idea  of  the  prognosis  of 
liematoma  is  expressed  by  the  latter  author.  Those  cases  of  hema- 
toma that  occur  in  the  latter  part  of  pregnancy  or  in  childbirth  or 
the  lying-in  are  much  more  serious  than  those  that  are  noticed  at 
other  periods,  and,  as  a  rule,  are  the  only  cases  concerning  which  any 
anxiety  need  be  felt. 

Symptoms. — The  eff'usion  is  more  gradual  than  in  hematocele — less. 


VKLVlc   ILKMAIOMA.  707 

pain  and  less  shock.  Kiiliiic  siiys  lliat  (lie  ])aiii  is  diU"  to  the  remliiij^ 
of  the  coniu'c'tivt'-ti.ssuc  clciiiciifs.  TIk."  pain  is  intermittent,  caused  hv 
the  suct'cssive  escapes  of  MihkI.  WC  may  note  the  ahsenee  of  peritonitis, 
meteorism,  and  ihc  dear  deliniiioii  of  tlic  line  of  (hdness  if  the  mass 
]>resents  above  ihe  ju'lvic  ImIiii.  Id  examinalion  l»v  the  vajjina  tlie 
tumor  is  found  just  within  tln'  \idva,  nearly  always  Ix-N.w  (he  noi-mal 
limits  of  I)oui;-las's  sac.  TxTnut/.  reports  cases  of  lateral  tunutr  at  the 
Junction  of  the  middle  and  lower  third,  and  existini;-  in  the  re<-to-\a<ii- 
nal  cells.  The  lateral  situati(»n  is  rare,  hut  when  found  it  is  character- 
istic of  a  hivniatoma  only.  Poncet  says  that  he  has  never  seen  luenia- 
tonia  develop  in  the  vaginal  wall  anterior  to  the  cervix ;  while  Nona 
has  rarely  seen  them  in  this  situation.  Prost  assigns  great  importance 
to  the  fact  that  h:ematoma  will  displace  the  uterus  upward,  just  as 
hieuiatocele  will  displace  the  organ  downward  and  forward,  while  the 
cervix  is  displaced  sometimes  to  the  right  or  left.  The  uterus  does  not 
lose  its  mobility  as  in  ha?matoeele.  Kuhne  calls  attention  to  the  bridge 
uniting  two  lateral  tumors,  which  has  been  already  described.  Through 
the  speculum  the  vagina  presents  a  violet  color  in  those  portions  con- 
tiguous to  the  tumor.  Nona  gives  this  appearance  high  diagnostic 
value,  but  according  to  Bernutz  it  is  not  alwavs  constant.  The  lucm- 
atoma  has  a  doughy  consistency,  a  false  fluctuation,  and  maintains  its 
characteristics  longer  than  hsematocele,  as  its  contents  change  less  rap- 
idly. Absorption  is  more  prolonged  in  hfematocele,  Avhile  the  latter  is 
more  disposed  t(i   rupture  into  the  rectum  or  the  vagina. 

Treatment. — The  primary  indications  are,  first,  to  arrest  hemor- 
rhage and  avert  or  mitigate  the  shock  ;  secondly,  to  treat  the  inflamma- 
tory complications,  and  lastly,  the  blood-poisoning  that  mav  result  from 
septic  changes  in  the  effused  blood. 

To  arrest  hemorrhage  we  may  employ  cold  irrigation  of  the  vagina 
or  rectum — three  to  five  minim  doses  of  the  liquor  sesquichloride  of 
iron,  sulphuric  acid,  tannin,  alum,  or  acetate  of  lead  and  opium,  avoid- 
ing hot  baths  and  hot  ajiplications,  sitz-baths  especially,  as  favoring  hem- 
orrhage. Shock  closely  follows  the  blood-loss.  The  head  should  be 
placed  lower  than  the  body  by  removing  pillows  and  I'aising  the  foot 
of  the  bed.  Vomiting  should  be  checked  l»y  pounded  ice,  Avhile  pain 
may  be  subdued  as  well  as  the  system  stimulated  by  ether  or  Hoff- 
mann's anodyne.  Moderate  use  may  be  made  of  stimulants  or  cor- 
dials, if  retained  l)y  the  stomach,  without  fear  of  renewing  the  hem- 
orrhage. Sinaiiisms  to  the  arms  or  inside  of  the  thio;hs  mav  be 
employed,  as  the  pain  of  the  application  retards  shock. 

The  cataclysmic  cases  are  treated  on  the  same  principle  as  rupture 
of  the  uterus  or  of  the  cyst  of  extra-uterine  pregnancy,  or  other  great 
pelvic  lesion  ;  when  peritonitis  is  present,  with  opium  and  the  hori- 
zontal position.     Purgatives  should  be  avoided,  as  breaking  the  law 


768  PELVIC  HEMATOCELE  AND  H.EMATOMA. 

of  rest.     The  bowels  will  probably  act,  as  in  other  cases  of  obstruc- 
tion, under  the  use  of  opium. 

In  from  twenty-four  to  thirty-six  hours  the  evidences  of  peritoni- 
tis present  themselves.  The  tonic  treatment  is  to  be  kept  up.  While 
excessive  tenderness  exists,  warm  poultices  or  fomentations ;  after  that 
stage  has  passed  blisters  may  be  applied  to  the  abdomen,  as  the  perito- 
nitis has  a  tendency  to  assume  a  chronic  form.  Bernutz  advises  us 
at  the  approach  of  a  menstrual  period,  provided  the  local  tenderness 
has  abated  to  a  sufficient  extent,  to  apply  leeches  through  a  speculum 
to  the  cervix  uteri  and  to  promote  the  flow  by  warm-water  injections. 
This  treatment  applies  to  the  menstrual  variety  of  ha3matocele.  Mc- 
Cormick  suggests  mercurial  plaster  to  the  abdomen  or  friction  with 
mercurial  ointment,  with  iodide  of  potash  internally ;  tonics  after  the 
subsidence  of  fever. 

Emmet's  treatment  is  hot-water  irrigation  to  control  inflammation, 
careful  nursing,  rest  in  bed  with  light  covering.  As  in  all  cases  of 
pelvic  or  abdominal  inflammation,  one  should  abstain  from  repeated 
vaginal  and  pelvic  examinations.  Make  one  as  complete  and  thor- 
ough as  possible,  if  necessary  under  ether,  for  diagnostic  purposes; 
then  stop. 

The  surgical  treatment  of  pelvic  hsematocele  may  now  be  regarded 
as  placed  upon  a  firm  basis.  Emmet  expresses  the  voice  of  the  period 
in  the  emphatic  assertion  that  surgical  interference  is  rarely  required. 
Bandl  has  formulated  two  rules :  First,  if  the  hematocele  is,  after  a 
week,  undiminished  in  size,  with  no  amendment  of  symptoms,  evacu- 
ate its  contents ;  second,  if  pus  or  sanies  appears  to  have  developed,  as 
proved  by  aspiration,  open  the  sac.  The  first  rule  does  not  conform  to 
the  practice  of  English  or  American  surgeons,  and  cannot  be  approved. 
We  may  suspect  the  degeneration  of  the  cyst  contents  into  pus  by  the 
presence  of  hectic  and  chills;  and,  having  proved  its  existence,  the  only 
treatment  that  can  afford  relief  is  to  apply  the  second  rule  of  Bandl. 
Barnes's  rules  have  in  a  large  measure  settled  the  practice.  When 
the  tumor  softens  and  moderately  enlarges,  with  high  pulse  and  tem- 
perature, septicsemia  is  present,  and  the  proper  time  for  operation 
has  arrived.  The  cyst  should  be  punctured  in  the  bulging  part,  behind 
the  cervix,  in  the  vaginal  roof,  with  a  moderate-sized  trocar  or  bistoury. 
The  instrument  should  be  inserted  in  the  direction  of  the  axis  of  the 
pelvic  brim,  parallel  with  the  posterior  uterine  wall.  A  sound  inserted 
into  the  uterine  cavity  will  aid  in  defining  the  direction  in  which  the 
trocar  should  be  inserted.  If  directed  too  much  backward,  it  is  liable 
to  wound  the  rectum  or  enter  the  sac  too  obliquely  for  free  evacuation. 
The  opening  may  be  further  enlarged  by  dilatation  if  necessary,  so  that 
clots  may  have  free  escape.  The  cavity  should  be  Avashed  out  daily 
with  carbolic-acid    solution    or  solution   of  mercuric    bichloride.     Sir 


i'i:i.vic  ii.KMA'ioMA.  7G9 

.1.  Sim|)-()ii  iiisislcd  nil  ;i  I'lci'  ii|iciiiiiL;-  in  pdvic  li;iiii;itiic(|f  :  "  1  iicmkc 
with  a  l('ii(it<nii\ -kiiilc  and  ciilaiLii'  il"'  opmini;'  wiili  llic  liniii'i',  hrcak- 
iiiii'  (low  n  septa  and  l)ln(Kl-('<)at;iila."'  Meadows  I'eeoniineiids  t  lie  very 
(loiil)tl'id  |»ra('tiee  of  |)nneliire  tlii'oiii;li  the  reeliini.  It  i>  onl\  neccs- 
sar\'  to  remark  that  e\aeiiation  ol"  the  sac  ihrouuh  tln'  reetuni  exposes 
the  palieiil  to  the  same  danLi'ei'  that  attends  .--pontaneoiis  cNaeiiatioti 
thron^ii  the  same  eliannel.  In  i'a>es  (»!"  old  luemaloceles  thiit  have 
sii|)puiate(|  ;nid  iii|tlnred  into  the  reetnm,  a  I'nrtJier  daii<2;cr  is  that 
thev  will  u'o  on  diseliar^iinL;,-  |)ns  for  years,  exhan.-t  in^;'  the  patient. 
Sneh  ea>es  nnisl  lie  treated  l)V  a  IVee  eonnter-(»peninii  into  the  vaii'ina, 
"  w  liieli  is  a  |>erleelly  snecessful  operation  "  (Tait).  The  last  anlhority 
Sii\s  that  ])nneliire  throiio-h  tlie  va<i;ina  rarely  Llives  relief.  ()p(,'nin<i; 
1)\-  the  ahdomen  is  not  justiliable,  and  tjie  one  ride  to  he  observed  is, 
that  all  cases  of  intraperitoneal  hseraatocele  out2;ht  to  be  left  to  Nature, 
unless  it  is  exceptional.  Cases  are  upon  reeord  (Aran)  in  which  after 
openinix  rapid  decomposition  took  place  within  the  cyst,  due  to  the 
entrance  of  air.  In  modern  practice,  with  antiseptic  precautions,  this 
dauLicr  ouu'ht   ro  be  remote. 

The  treatment  of  hematoma  is  based  upon  the  same  general  plan. 
Snriiical   interference  is  rarely  required. 


DIULIOGHAPHICAL  NOTE  TO  ARTICLE  OS  '•  MENSTRUATION,  AND  ITS 

DISOnUERS." 

As  an  explanation  for  tlie  absence  of  any  reference  to  several  papers  and  discnssions 

on  Menstruation  that  have  appeared  in  the  journals  in  the  past  eighteen  months*  1 

will  say  that  my  article  on  Menstruation,  and  its  Disorders,  was  written  in  the  tall 

and  winter  of  1885,  and  was  ready  for  the  press  Feb.  1,  1886.    When  tiie  proof-sheets 

were  retin-ned  to  me,  I  found  it  impracticable  to  change  it  without  rewriting  most 

of  it.  and  it  was  left  in  its  original  state.     Selected  parts  were  read  before  the  meeting 

of  tlie  Alumni  Association  of  tlie  New  York  State  Woman's  Hospital,  Jan.,   1S86, 

but,  at  llie  request  of  l)r.   Mann,  they  were  not  published. 

W.  Gill  Wylie. 
June  17,  1SS7. 

Vol.  I.— 49 


AUTHORS'  INDEX. 


[See  also  lists  of  Lilenttmr  ivlonvd  to  on  pp.  03,  278,  548,  568,  586,  593,  599,  618,  635.] 


A. 

.\ili>l(>n,  445 

AjiiKw,  I).  H.,  28,  41,  725 

Aikinim.  John,  252 

Alhuc.isis,  22 

Aiulral,  09") 

Apnstoli,  387,  399,  400,  403 

Appletoii,  22 

Aran,  377.  568,  664,  677,  696,  707,  723,  727 

752,  7()9 
Arcliigenes,  676 
Ai'tiiis,  20,  676 
Atiee,  J.  L.,  27 
Atlee,  W.  L.,  27,  28,  64 
Atthill,  568,  580,  653,  664 

B. 

Bainl,  60 

Baker,  W.  II..  02,  261 

Balfour,  86,  176 

Ball,  John,  41,  433,  765 

Bandl,  163,  219,  707,  736,  739, 

755,  756,  760,  761,  762,  705, 
Barl)oiir,  101 

Barker.  Fonlvce.  38,  395,  484,  58 
Barnes,  Eobert,  568,  581,  583, 

738,  740,  742,  750,  755,  756, 
P>ai"stellbero;ef,  203 
Battey,  Robert.  36,  3S,  39,  49 
Bear<l  and  Rockwell,  385 
Beck,  Jos.  E.,  43,  433,  705 
Beck,  Snow.  039,  640,  738,  745,  755 
Becqnerel,  727 
Bedford.  G.  D.,  30,  03,  738 
Behier,  709 

Bei<i;el,  70,  167,  738,  765 
Bell,  24 
Bennet,  377,  568,  571,  573,  576,  581,  661, 

738 
Bernutz,  508,  677,  687.  688.  089, 

694,  695,  696,  700,  704,  715, 

735,  730,  737,  739.  740,  742, 

760.  70).  760,  767,  768 
Bigelow,  Henry  J.,  52 
Bi<;elow,  H.  R..  57 
Bi Hinder,  J.,  27 
Billroth,  712 
Bird,  547 
Bisciioff,  409 
Bixby,  G.  H.,  03,  725 


741, 
768 

>1 

722, 

768 


745, 


736, 


691, 

693, 

717, 

727. 

752, 

755, 

Boehni,  C,  93 

Boerner,  000 

Boisin  and  Diifjcs.  447 

Boisin,  Mad.,  157 

Bouchnt,  698 

Boynhain,  Wm.,  28 

Bozenian,  Natlian,  34,  36,  445 

Brandt,  616 

Braun,  C,  508,  738,  755 

Breiskv,  20O 

Brickell,  4(5,  49 

Briddon.  Charles  K.,  56 

Broca,  100 

Browne,  B.  Bernard,  57 

Budin,  P..  93,  119 

Bumstead,  593 

Burns,  640 

Buttles,  M.  S.,  39 

Byford,  W.  II..  36,  45,  56,  63,  66,  542,  568, 

581,  723,  725,  728,  733 
Byrne,  Joiin,  38,  62,  64,  738 

c. 

Cadiat,  124 
Campbell.  H.  F.,  45 
'  Carrard,  477 
Carreau,  J.  D.,  681 
Carrington,  224,  225 
Chadwick,  J.  R.,  45,  46.  53,  198,  199,  480, 

692 
Cliampionniere.  554.  679,  080 
Channing,  AValter,  30 
Chajiman,  E.  X.,  63 
Chauvau,  93 
Chrobak.  135.  141 
Chroniel,  041.  601 

Cluirchill,  Fleetwood,  040,  670.  738 
Clark,  29 
Clark.  Alonzo.  30 
Clark.  C.  M..  531 
Clark,  Edward  H..  45 
Coe,  H.  C,  01,  330,  69S.  699 
Coen,  242 

Coleman.  J.  D.,  259 
Cooper,  Astlev,  483 
Cornil,  91,  519 
Couriv,  A.,  91,  93.  445,  554,  568,  581,  641, 

604,  680,  681,  709,  715,  723,  740,  746, 

703.  766 
Crede,  738 

771 


772 


AUTHORS'   INDEX. 


Creighton,  178 
Cruveilhier,  252 
Cnllerier,  593 
Cuilingworth,  C.  J.,  691,  722 

D. 

Dal  ton,  178 

Davies,  Gomer,  258 

Davis,  E.  Y.,  515 

Dawson,  B.  F.,  63 

Deces,  742 

Delore,  756 

Del  rand,  515 

Denouviliers,  737 

Deralz,  740 

Dewees,  Wm.  P.,  63 

Dohrn,  E.,  72,  93,  262 

Dolbeau,  741,  757 

Doran,  180 

Douglass,  22 

Doutrelepont,  519,  523 

Drysdale,  Thomas  M.,  43,  64 

Duhring,  534 

Duncan,  Matthews,  252,  465,  519, 

657.  677,  688,  694,  695,  705, 

73S' 
Dunglison,  588 
Dunlap,  A.,  27 
Duparque,  593,  641 
Duverney,  746 

E. 


520, 527, 
722,  723, 


Frey,  121 
Friedlander,  141 

Fritsch,  154,  354,  561,  568,  688,  701,  707, 
716,727- 

G. 

Galabin,  527,  653,  662 

Gallard,  735,  736,  737,  759,  761 

Gantillon,  377 

Garrigues,  56,  140,  192,  210,  228,  706,  719 

Gartner,  Herman  T.,  70,  93 

Geigel,  K.,J0,  93 

Gendrin,  377 

Gillette,  531 

Gilmour,  38 

Giraldez,  75 

Giranlt,  475 

Goodell,  Wm.,  36,  40,  42,  50,  54,  58,  66, 

359,  433,  517,  530,  568,  617 
Goodman,  46 
Goupil,  687 
Graaf,  Regnier  de,  80 
Grandin,  Egbert  H.,  667 
Green,  T.  Henry,  536,  679 
Greenhalgh,  356 
Grobe,  236 
Gross,  26,431 

Guerin,  Alph.,  217,  709,  715 
Gussenbauer,  109 
Gusserow,  155,  761 
Gurlt,  537 


Edis,  542,  568,  637 

Elischer,  175 

Ellinger,  433 

Ellis,  189,198,224,231 

Emmet,  T.  A.,  34,  35,  36,  37,  41,  42,  43,  44, 
50  54,  55,  63,  65,  199,  234,  252,  337, 
338,  530,  597,  667,  680,  699,  704,  707, 
714,  718,  720,  721,  722,  729,  738,  742, 
743,750,768 

Engelmann,  50,  141,  331,  387,  400,  403, 
409 

Erich,  499 

Eustache,  476 

F. 

Fallopio,  Gabriele,  87 

Far  re,  169 

Fayrer,  525 

Fenger,  Christian,  55 

Fenwick,  Bedford,  529 

Finn,  646 

Fischel,  W.,  93 

Forstei',  593 

Fort,  C.  H.,  263 

Foster,  Frank  P.,  102,  118,  228,  233,  234, 

362,  554,  698 
Foulis,  84,  93 
Franck,  737 

Frankenhilnser,  146,  762 
Frarier,  709 
Freund,  708 


H. 

Hadra,  B.  E.,  59 
Hagemann,  93 
Harrison,  738 

Hart,  D.  Berrv,  682,  686,  724 
Hart  and  Barbour,  101,  106,  109,  112,  125, 
131,  132,  154,167,168,  188,212,222, 
2'?7   228,  229,  233,  568,  602,  638,  644, 
688',  708,  751,  761,  762,  764 

Heath,  224,  229 

Heath,  W.  H.,  483 

Hedenius,  P.,  93 

Heo-ar,  149,  578,617 

He'lie,  135,  137 

Henle,  121,  142,  172.  187,  188,  189,  230 

Hening,  137,  163,  169 

Hennig,  536,  568,  582 

Heppner,  269 

Hermann,  107 

Herrick,  O.  E.,  56 

Herzfelder,  738 

Heschl,  600,  645,  746 

Hewitt,  Graily,  622,  654,  663,  738,  /o9 

Heyer,  738 

Hey  wood,  478 

Hicks,  Braxton,  694 

Hildebrandt,  498,  499,  515,  537,  539 

His,  W.,  94 

Hodge,  H.  L.,  29,  63,  599 

Hodgen,  487 

Hoggan,  643 

Holden,  187,  497 

.  Holyoke,  22 


.1  rrimiis-  f\in:x. 


lis 


FI<i\vnrd.  Win.  T.,  '>X 

H.i-iiier,  ii:i.  .'.11.  ::'.<■' 

Iliiiiior,  "Jo 
IliiiUfr,  J.  H..  •'>•'- 
lliitrliiiison,  ii'l'i,   't'Si 
llvatt.  II.O..  iM 

11  "v 111,  l'.»s.  -jiw;.  .■)!(; 


111..},  i:..  414. 

Imbeit,  G..  94 


I. 


J. 


.linkson.  A.  K.-oves,  39,  53,  536,  616 

.Jtuolii,  64 :;.  644.  ()46.  647,  652 

Jaiulii.   Marv  Putnam,  59,  41U,  437,  602, 

(13S,  tMl".  647,  662 
Jacobsoii.  L..  94 
Jenks,  Ivlwanl  W.,  52.  55,  513 

K. 

Kaltzenbach,  578 

Kam merer,  377,  454,  462 

Kaposi,  527 

Kasciikaroff,  660 

Kehrer.  421,441,  462,617 

Kelly,  H.  A.,  58 

Keiinedv,  536,  580 

KerkrinV,  239 

Ki.M,  5S0 

Kimball,  Oilman,  45,  61 

Kiiia,  John.  28 

Kirmisson,  534 

Kiwisch,  511,  542,  547,  599,  638 

Klehs,  268,  271,  738 

Klein.  121,  139,  142,  164,  172,  176,  190 

Klemni,  5S2 

Klob,  534,  539,  542,   546,   574,  599,  601, 

608,  637,  645,  649,  650,  660 
Kobelt,  104,  109,  112 
K<.eh,  519,523,  530 
Kocks,  J.,  71,  94 
Kulliker,  A.,  69,  73.  79,  83,  84,  85,  91.  94, 

237 
Konig,  219,  723 
Krause,  104 
Kreiger,  738 
Kiiluie,  766,  767 
Kmulrat,  409      ' 
Kiissmaiil.  247 
Kustner,  539 

L. 

Lallemand,  581 

Lamballe,  J.  de,  377 

Lani^enbeck,  242 

Langier.  737 

Langlade  and  Cum  men,  239 

Lazarewilch,  655 

Le  P.ee,  123,  131.  146,  687 

Lebeeleff,  261 

Lee,  C.  C,  55,  738,  740 


Lefort,  243 

Lenoir,  737 

Lente,  I".  D.,  39,  57H,  581. 

Leopidd,  129,  140,141,172,409,554,643, 

644,  679,  680,  687 
Lever,  640 
Lew,  454 
Lewi.s,  \V..  63 
Lindgien,  142 
LislVani-,  599,  638 
Lister,  165,  339 
Litzman,  443 
iMtt.  141 
Louis,  261 
Lowenthal,  309 
Luschka,  102,  121,  132,  169,  186,  188.  19.3, 

221 
Lusk,  101,  107,  142,  492,  536,  651,  711,  713 
Lyraan,  Geo.  H.,  28,  48,  731 


I  M. 

Mct'arthv,  Justin,  705 
'McClintock,   A.,  532,  677,   707,  711,728, 
I  735.  736,  738,  750,  752 

McCormick,  758.  768 

McDowell,  23,  29,  30 
I  Madge.  738,  740,  755,  762 

Mann,  Matthew  D.,  56,  127,  131,  334,  339 

Mapother.  447 

Marchal,  676,  677 

Marrotte.  761 

Marsh,  Howard,  727 
t  Martin,  t)48 

Martin,  Franklin  H.,  365,  617,  666 

Mason,  477 

Massot,  532 

Maver.  243,  527,  538 

Meadows.  736.  738,  739,  742,  761,  769 

Meigs,  C.  D.,  29,  63,  502,  654 

Meniere,  405 

Meyer,  H.,  77,  94,  271 

Mever.  Leopold.  236 

Miller,  Henrv.  .377,  581 

Milne,  Edwaixls  H..  70,  94 

Minor,  Julius  F.,  38 

Mitchell,  Weir,  610,  633 

Monod,  737 

Morel,  237 

Morris.  722 
I  Muller.  J.,  85 

Munde.  50.  53,  66,  250,  327,  398,  405.  443, 
444,  480,  528,  554,  561,  578,  666,  679, 
I         681 

!  X. 

Nandier.  710,  715 

Nega,  242 

Nelaton,  735,  736,  737,  745,  747 

Newman,  Robert,  61 

Xickles.  663 

iNoeggerath.  E.,  37,  38,  45,  48,  431.  459. 
1         460,  571,  599,  608,  617,  638,  660,  691 

Nona,  767 
(  Nonat,  627,  677 


774 


AUTHORS'   INDEX. 


Nott,  J.  C,  30,  377,  516,  518 
Nylander,  141 

o. 

Olshausen,  209,  23G,  617,  652,  713,  738,  765 
Oribasius,  676 
Orne,  22 
Osgood,  22 
Ott,  737 

P. 

Paget,  527,  552,  731 

Palfyn,  261 

Fallen,  Montrose  A.,   45,  443 

Palmer,  C.  D.,  35,  57 

Pare,  Ambroise,  22 

Parry,  John  S.,  39 

Parvin,  Theophilus,  38 

Pattee,  A.  F.,  62 

Pauliis  JEgineta,  21 

Pauly,  742 

Peaslee,  36,  37,  64,  243,  245,  ;;77 

Peuch,  737 

Peuch,  A.,  94,  236,  237,  255,  743 

Pfluger,  176,  409 

Phillips,  758 

Physick,  26 

Pick,  524 

Pirogoff,  212,  488,  683 

Playiair,  568,  580,  633 

Polk,  Wm.  M.,  56,  60,  192,  193,  210,  212, 

215,  682,  688,  698,  699,  717 
Poolev,  J.  H.,  261 
Post,  Alfred  C,  58 
Post,  Sarah  E.,  60 
Poncet,  737,  740,  749,  751,  754.  756,  765, 

766 
Priestley,  542 
Prochownick,  239 
Prost,  737 
Puzos,  676 

Q. 

Quain,  94,  105,  107,  112,  136,  224 

R. 

Raciborski,  740 

Paine}',  159 

Eannev,  101,  102,  105,  108,  113,  131,  141, 

218,  228,  233 
Rasch,  759 
Eecamier,  22,  30,  581 
Eeinmann,  547 
Reyer,  525 
Richard,  476 
Richardson,  W.  L.,  719 
Richet,  740 
Ricard,  593 
Rieder,  Carl,  72,  94 
Rindfleisch,  748 
Ringer,  Sidney,  365,  662 
Robert,  737 
Robin,  C.  H.,  124,  707 
Rogers,  D.  L.,  27 
Ro'kitansky,  248,  546,  743 
Rose,  Cooper,  245 


Rosenmiiller,  75 
Ronget,  139 
Routh,  477,  568 
Ruge  and  Veit,  143,  587 
Ruysch,  737 

S. 

Sanderson,  678 

Sanger,  536 

Savage,  98,  99,  108,  109,  121, 135,  140, 157, 

183,  186,   188,  189,  210,  226,  229,  684, 

701,  723,  724 
Scanzoni,  377,  516,  541,  547,  568,  599,  637, 

641,  652,  661,  664,  722,  738,  740,  745 
Schafer,  216 
Schroeder,   118,  354,   477,   480,  528,  542, 

568,  617,  644,  646,  654,  705,  722,  738, 

746 
Schiiller,  180 
Schultz,  654 
Schultze,  718 
Sch upper t,  M..  38 
Schuregius,  515 
Schwimmer,  524 
Scott,  John,  59 
Scultetus,  22 
Sedgwick,  86 
Sei'dukopf,  Ar.,  655 
Shatz,  F.,  94 
Silvestre,  749 

Simon,  29,  187,  617,  709,  710,  715 
Simpson,  A.  R.,  653,  724 
Simpson,  Jas.,  377,  511,  516,  536,  568,  637, 
-  638,  640,  641,  644,  646,  C61,  664,  727, 

732,  738,  769 
Sims,  J.  Marion,  30,  34,  36,  37,  39,  45,  60, 

63,  475,  514 
Sinclair,  600 
Sinety,  L.  de,  91,  94,  116,  117,  124,  125, 

140,  143,  167,  475,  587,  644,  647,  652 
Sireday,  752 

Skene,  Alex.,  46,  48,  65,  71,  94,  185,  188 
Smellie,  23 
Smith,  A.  G.,  27 
Smith,  N.,  27 
Smith,  Tyler,  568,  739 
Smyly,  759 

Spiegelberg,  607,  686,  688 
Stearns,  26 
Steurer,  706 

Storer,  H.  R.,  36,  38,  63,  450 
Strieker,  140 
Stroinsky,  O.,  55 
Snrgus,  Damien,  496 
SussdorfF,  322 


T. 

Tait,  Lawson,  169,  172,  180,  267,  409,  503, 
505,  509,  519,  688,  691,  695,  701,  704, 
705,  722,  724,  729,  730,  738,  74:-,  752, 
766,  769 

Taliaferro,  V.  A.,  38 

Tardieu,  262,  741 

Tavlor,  I.  E.,  28,  57,  241,  259,  519,  567 

Thin,  520,  527, 


Al'TlinliS'    IXDh'X. 


Thomas,  T.  G.,  '2S.  M,  38,  49,  "j1,  .'.4,  .")•.», 

(;:;.  118,  ;5')6,  4S(),  510,  ois,  o4'_',  r.iiT, 
o(js,  ")S(),  .")Wit,  (>17,  (i.'Js,  (ii:!,  (ic.o,  ()(;i. 

«i(i4,  ()77,  70.'),  710,  7U7,  7;{li,  738 
Tilt.  7:58,  7.'5'.» 
Tripier,  .SIMI,  7(i4,  7(1"> 
Tnmssi'iiii,  o()"J,  710,  74'. 
TiinuT,  141 
Tiiniipsei'd,  Iv  !!.,  'J<!.'> 


w 


74:! 


ririi'ii,  7;;8 


u. 


V. 


\';in   lliinu,  \\  in.  II.,  (>78 

\ai>  .lo  \V:uk.i-,  Iv,  ol,  53,  132 

Veil,  72:'. 

\'el|)eau,  077 

Vi<lal,  527,  582 

Vifliiis,  7:37 

Vireiiow,  2:57,  520,  527,  547,  075,  678,  701, 

705,  7:iS,  741 
Voisin,  7:^7,  738,  7:^9,  743,  748,  751,  755 
Von  Haselberg,  583 
Von  i'reuscliin,  124 
Von  Kecklinghausen,  706 


■,  270, 


Wal.lrv.T,  W.,  08,  81,  80,94,  17 

(i78 
WalkcT,  II.  v.,  252 
Wanvii,  .1.  ('.,  27,51 
\Va.s.sili(.-(r,  M.,  72,  94 
Walts,  R..  72 
Wi-l,stor,  10.  II.,  :540 
Wells,  SponctT,  KW,  480,  742 
Wernick,  AVA 
West,  508,  077,  710 
Wiiitc,  J.  C,  523 
White,  J.  P.,  30,  37 
Whiltaker,  J.  T.,  242 
Williams,  141,  144,  155,  400.  759 
Wilson.  ICllwood,  067,  672 
Wiltshire.  700 
Winekel,  T.,  94,  186,  230,  415.  401,  488, 

491,  497,  530,  5:W.  078,  723,  740 
Wolf!"  Casper  Friediieh,  08 
Wun(lerliL4i,  694,  702 
Wylie,  G.,  L35 


Z. 


Zweilel,  515,  536,  538 


INDEX   TO    N'OLIIME    I 


A. 

Abdomen,  exnininatinn  of,  30(3 

inspei'lioii  dt',  'MM 

ineiisuratioii  of,  .'iOT 

palpation  of,  307 
Aljcloniinal  section  in  pelvic  pcritunilis,  in- 
dications for,  704 
Abdomino-rectal  exaniinatinn.  ;;i)l 
Abortion,  treatment  of  hemorrhage  after, 

Abscess,  chronic  ]ielvic,  o6,  60 
pelvic,  7"J1 

asjjirating  sac,  731 
diagnosis  of,  726 
opening  sac,  7'2S 
pathological  anatomy,  722 
sinuses,  73.! 
treatment  of,  727 
Acute  eczema  of  vnlva,  503 

metritis,  546 
Adenitis,  periuterine,  680,  759 
Aileno-lymphangitis.  680,  759 
Adhesions,  pelvic,  treatment  of,  51-54 
Air,  fresh,  iniportaiu-e  of,  622 
Alcoholics,  use  of,  624 
Alexander's  operation,  160 
Alopecia  of  vnlva,  500,  501 
Amenorrhoea,  411 
electricity  in,  3;il 
treatment  of,  364,  413 
Amputation  of  cervix,  high,  150 

in  metritis,  617 
Ana\stl)esia  in  operations,  338 
Angeioleucitis,  ()80 
Angioma  of  vulva,  536 
Anteflexion,  cause  of  dysmenorrhoea,  423 

of  uterus,  256 
Antisepsis,  agents  for,  329 

in  gynecological  operations.  328 
Antiseptic  injections  in  childbed,  662 
Aiuisciitit's  in  lupus,  523 
Anus,  lissure  of,  causing  dyspareunia,  453 
Apoplexy  of  ovary,  745 
Appendages,  uterine,  161 

disease    of,    complicating    dvsmenor- 
rhrea,  420 
Applications,  intra-uterine.  agents,  381 
by  applicator  syringe,  578 
bv  ingestion.  577 


Api>lications,  intrauterine  method,  380 

topical,  in  endometritis,  559 
Applicator,  cotton-wrapped,  577 

hard  rubber,  564 

Sims's.  580 
.\|iplicator  .syringe,  578,  581 
Arlior  vitiu  ntcrina,  134,  137 
Arsenic,  use  ol',  in  metritis,  612 

value  of,  372 
Arteries  of  ovaries,  179 

uterus,  143 
Artificial  im[)regnation,  475 
Aspermatism,  453 
Aspiration  for  diaguusLs,  326 
Aspirators,  326 
Assistants  in  operations,  340 
Astringents  in  congestion,  563 
Atresia  ani  vaginalis,  261 

of  hymen.  262 

of  uterus,  253 

of  vagina,  257,  458 

of  vulva,  267 

treatment  of,  478 
.^.trophy  of  uterus,  599 

treatment  of,  618 
Auscultation  and  percussion  of  abdomen, 
306 

B. 

Bacillus  tuberculosis  in  lupus,  519 
Bartholin, glandsof,  113.  (SeeVulvo-vaginat 

Guind.) 
Bathing  in  uterine  disease.  621 
Baths,  hip,  in  subinvolution,  663 

stni,  621 
Battey's  operation,  39-49 
Battey  on  removal  of  ovaries.  39,  49 
Belladonna,  action  of,  370,  373 
Bimanual  examination,  method,  298 
Bladder,  anatomy  of,  gross,  188 
minute.  190 

diseases  of,  works  on,  65 

ligaments  of,  207 

relations  and  attachments,  191 

sphincter  of.  189 

supports  of  225 

symptoms,  importance  of,  29] 
Bleeding,  local,  in  chronic  metritis,  613 
Boils  on  vulva,  494 
Bowels,  atteniidu  to  lunction  of.  .370,  62f6 


778 


INDEX  TO    VOLUME  I. 


Broad  ligaments,  207 

contents  of,  209 

in  pregnancy,  208 
Bromides,  value  of,  365,  374 
Bulb  of  ovary,  180 
Bulbs  of  vagina,  112 

of  vestibule,  112 
Bursting  cysts  of  abdomen,  54 
Buttle's  spear,  613 
Buttonhole  incision  of  urethra,  54 

C. 

Cancer  as  a  cause  of  metrorrhagia,  417 
of  cervix,  excision  for,  62 
of  vulva,  537 

pelvic,  diagnosis  from  hajmatocele,  761 
Carbolic  acid  in  dj'smenorrhoea,  428 
Carcinoma  of  vulva,  539 
Caruncles  of  urethra  causing  dyspareunia, 
451 
electricity  in,  404 
Carunculse  myrtitbrmes,  118 
Cases,  rational  history  of,  284 
Catgut  for  sutures,  339 
Catheter,  passing  the,  115,  197 
Cedron  as  tonic,  369 
Cellulitis,  pelvic,  705 
diagnosis,  714 
from  fibroids,  718 
from  hsematocele,  717 
electricity  in,  404. 
etiology,  706 
exudation,  seat  of,  715 
pathology,  708 
prognosis,  718 
pus  in, 710 
symptoms,  710 

non-puerperal,  713 
puerperal,  711 
treatment  of,  60 
curative,  719 
prophylactic,  718 
remarks  on  treatment  of,  220 
Centennial  year,  46,  49 
Cervical  protector,  Wylie's,  428 
Cervix,  amputation  of,  in  metritis,  617 
anatomy  of,  587 

appearances  of,  in  Sims's  speculum,  314 
congestion  of,   glycerin    and    boro-giy- 

cerides  in,  562 
cystic  degeneration  of,  591 
false  ulceration  of,  587 
forcible    dilatation    of,   41.      (See   also 

Dilatation.) 
granular  degeneration  of,  589 
high  amputation  of,  150 
in  laceration,  149 
in  old  age,  149 

lacerations  of,  causing  subinvolution,  651 
operation  for  lacerated,  58 

history  of,  37 
pathological  anatomy  of,  588 
pelvic   peritonitis  following   operations 

upon,  698 
shape  and  size  of,  133 


Cervix,  stenosis,  dangers  of  incision   for, 
151 
syphilitic  ulceration  of,  593 
true  ulceration  of,  593 
Chadwick's  table,  295 
Change  of  life,  436.     (See  Menopause.) 
Chloral,  use  of,  374 
Chromic  acid  as  application,  566,  580 
Chronic  eczema  of  vulva,  514 
metritis,  602 

hot  douche  in,  613 
quinine  in,  630 
sponge  tents  in,  616 
pelvic  abscess,  56,  60 
peritonitis,  696 
Clinic,  first  gynecological,  30 
Clitoris,  anatomy  of.  106 
attention  to,  necessary,  621 
hypertrophy  of,  447 

treatment,  477 
malformations  of,  266 
Cocaine,  use  of,  381 
Coccyodynia,  516 

causing  dyspareunia,  452 
Nott  on,  30 
Coccyx,  neuralgia  of,  516 

removal  of,  518 
Cofiee,  use  of,  624 

Coitus  during  menstruation,  effects  of,  743 
excessive,  as  cause  of  subinvolution,  652 
hindrances  to,  from  malformations,  446 
impossible,  causes  of,  446 
painful,  448 

spasm  in,  from  vaginismus,  515 
Colica  scortorum,  701 
Columbia  Hospital,  report  of,  41 
Condyloma,  examination,  298 
syphilitic,  of  vulva,  531,  534 
venereal,  of  vulva,  537 
Congestion,  use  of  astringents  in,  563 
Conjoined  examination,  298 
Connective  tissue,  pelvic,  215,  684 
continuity  of,  219 

practical  deductions  on  anatomy  of, 
219 
Constipation,  treatment  of,  390,  627 
Constitutional  treatment  of  chronic  uterine 

disease,  363,  619 
Constriction  at  os  internum,  152,  421 
Contraction  of  os,  561 
Corpus  luteum,  hemorrhage  from,  745 
Counter-indications  of  hot  douche,  559 
Course  of  chronic  metritis,  601 

of  subinvolution  of  uterus,  659 
Cowper's  glands,  analogues  of,  113 
Cumulus  ovigerus,  83 
Cupping  the  uterus,  614 
Curette,  in  endometritis,  596 
forceps,  of  Emmet,  597 
Eecamier's,  596 
sharp,  use  of,  567 
Simon's  spoon,  361,  597 
Sims's,  latest  form  of,  418 
Thomas's,  360,  596 
used  for  diagnosis,  324 
varieties  of,  324 


IMUX    TO    VOLT  Ml-:   I. 


CiircttiiiLr,  mc'tliiMl  of,  odS 

tlie  ccivital  raiial,  'iliT 
Ciini'iit,  olfftriral,  sliciintli,  .'!S7 
Cyst  1)1"  [larovariimi,  7") 

i>l'  rtiuiid  li^^aiiK'Ht,  case  of,  4SS,  'V,\'j 
Cystic  (k'lii'iK'iatiiMi  of  cervix,  o'Jl 
Cystocclc,  (Icliiiiiiiiii  of,  -jS7 
Cystntoiiiy,  rj(> 
Cysts,  Itiirstiiiji,  of  ali(iniiicii,  ')4 

of  (riirtiiers  canal,  72,  hob 

of  rouiiil  lif^aiiiL'iit,  4S8 
Ciise  of,  i).'i") 

of  vulva,  b'.W 

of  viilvo-vajjiiial  f:;lan(l,  034 

sebaceous,  of  vulva,  ')ib 

D. 

Da.sjijjet's  oxarniniug-table,  29G 

Decidua,  uterine.  140 

Detecation.  importance  of,  as  a  svinptom, 

Denuilation  in  plastic  operations,  340 
Depletion,  local,  o<j"2 

in  chronic  metritis,  613 
uterine,  value  of,  37!) 
Depressor,  Sims's,  311 
Diagnosis,  artilicial  prolapse  of  uterus  in, 
325 
gynecoloiiical,  2S3 
of  chronic  metritis,  H06 
of  early  pregnancy,  149,  151 
of  endometritis,  chronic  cervical,  554 

corporeal,  574 
of  masturbation,  478 
of  pelvic  cellulitis,  705 
ha?matocele,  757 
ditierential,  763 
from  cellulitis,  717 
from  liffimatoma,  761 
htematoma,  766 
peritonitis,  697 

from  hiematocele,  759 
of  periuterine  inllamniation,  658 
of  phlegmon    of  broad    ligament    from 

pelvic  hiematocele,  7(j;> 
of  retroflexion  of  gravid  uterus,  758 
of  sterility,  464 

of  subinvolution  of  uterus,  655,  659 
of  tumors  from  subinvolution,  658 
position  of  uterus  in,  300 
use  of  microscope  in,  327 
Diaphragm,  pelvic,  223 
Diet,  importance  of,  in  disease,  622 
Dietetics,  directions  for,  368 
Digestion,  attention  to,  625 
Digital  examination  in  left  lateral  position, 
310,315 
method,  298 
Dilatation  of  cervix,  advantages  of  dili'er- 
ent  methods,  357 
by  sounds.  359 
dans;ei"s  of,  359 
for  diagnosis,  319 
for  surgical  purposes,  354 
forcible,  41.  153 


Dilalatiiin    of  cervix,    in    dvsiiiciiorrhii-a, 

427,  433 
Dilatr)rs,  uterine,  l^mmei's,  .'521 
Frit.sch's,  358 
(ioodell's,  :;i9 
H:uiks'>,  320 
Molesworth'.s,  320,  322 
Nott's,  358 
Palmer's,  .".20,  560 
Peaslee's,  559 
Schultze's,  358 
Sims's,  427 
Dimensions  of  uterus,  132,  152 
Diphtheritic  vulvitis,  4!»2 
Discharge,  vaginal,  as  a  symidom.  292 
Discus  proligeru.s,  83 
Disorders  of  menstruation,  electricitv  in, 

388 
Displacements  cause  sul)involiition,  ii53 
geuu-[)ectoral  position  in,  46,  129 
uterine,  electricity  in,  390 
Dividsion  in  dysmenorrluea.  429 
Dorsal  position  in  examination.  297 
Double  uterus,  preiinancy  in,  252 
relation  to  superf(etatiou,  253 
va<^iua,  259 
Douche,  hot-water,  379,  414 
counter-indications,  559 
in  cervical  endometritis,  556 
in  chronic  metritis,  613  • 

in  endometritis,  545 
in  pelvic  peritonitis,  754 
indications,  558 
mode  of  use.  557 
Douglas,  folds  of,  210 
Douglas's  pouch,  anatomy  of.  211 
boundaries  of,  683 
dangers  of  wounding,  127 
depth  of,  214 

intestines  in,  147,  212.  488 
Drainage  in  ovariotomy,  45 
Drainage-tubes,  Wylie's  intra-uterine.  429 
Dress,  importance  of  attention  to,  621 

rules  for,  610 
Ducts.  ( nirtner's,  70 
Miillerian.  85 
Skene's,  71 
Wolffian,  68 
Duverney,    glands    of.  113.      (See    Vulva- 
vaginal.  ) 
Dysmenorrhcea,  419 

caused  by  retroflexion,  423 
causes  of,  421 
classes  most  liable  to,  424 
complications  of,  420 
divulsion  in.  429 
electricity  in.  390 
forcible  dilatation  in.  433 
glycerin  and  boro-glycerides  in,  426 
membranous,  434 
pessaries  in.  434 
treatment  of.  425 
by  dilatation,  427 
by  divulsion.  429 
by  soinids,  4'>3 
by  sponge  tents,  433 


780 


INDEX  TO    VOLUME  I. 


Dyspareunia,  causes  of,  448-452 

caused  bv  lacerations  of  cervix,  458 


E. 

Eczema  of  vulva,  503 

chronic,  514 
Electrical  current,  dangers  from,  in  extra- 
uterine pregnancy,  406 
strength  of,  387 

in  extra-uterine  pregnancy,  406 
in  uterine  fibroitls,  4()2 
Electricity,  in  amenorrhcea,  391,  414 
in  chronic  pelvic  inflammation,  404 
in  diseases  of  menstruation,  388 
in  dysmenorrhoea,  390 
in  exti-a-uteriue  pregnancy,  405,  406 
in  fibroid  tumors,  399 
in  hyperplasia  uteri,  404 
in  menorrliagia,  391 
in  ovarian  tumors,  398 
in  ovaritis  and  ovarian  neuralgia,  393 
in  periuterine  hsematocele,  397 
in  subinvolution  of  uterus,  393 
in  subinvolution  of  vagina.  672 
in  siiperinvolution  of  uterus,  395 
in  uterine  displacements,  396 
in  uterine  stenosis,  405 
note  on  use  of,  632 
use  ofV  in  gynecology,  373,  383 
Electrization,  localized,  method  of,  385 
Electrodes,  covering  of,  387 

size  of,  388 
Electrolysis  in  fibroids,  399 
electrodes  in,  404 
in  ovarian  cysts,  50 
pain  in,  401 
results  in,  403 
strength  of  current  in,  402 
Elephantiasis  Arabum,  524 

distinguished  from  fibroma  diffusum,  527 
Emmenagogues,  366,  414 
Emmet's  needle-holder,  348 
ojjeration,  invention  of,  37 
Enchondroma  of  vulva,  536 
Endocervicitis,  silver  nitrate  in,  564* 

use  of  zinc  in,  565 
Endometritis,  acute,  541 

as  a  cause  of  subinvolution,  652 
caused  by  gonoiThoea,  542 
chronic,  548 
cervical,  549 
cause,  551 
complications,  554 
diagnosis,  554 
frequency,  549 
hot  douche  in,  556 
pathology,  550 
phj'sical  signs,  553 
prognosis,  555 
symptoms,  552 
treatment,  555,  560 
corporeal,  568 
cause,  570 
diagnosis,  574 
frequency,  568 


Endometritis,  chronic   corporeal,  pathol- 
ogy, 569 
prognosis,  575 
symptoms,  572 
treatment,  575 
ingestion,  577 
local  method,  577 
general,  568 
fungoid,  574 

curette  in,  596 
hot  douche  in,  545,  556 
septic,  545 
silver  nitrate  in,  581 
Enucleation  of  fibroids,  44,  45 

of  pedicle,  38 
Epispadias,  265 

treatment  of,  477 
Epithelioma  of  vulva,  537 
Erectile  organs  of  female,  108 
Ergot,  action  of,  on  sexual  organs,  371 
discovery  of  26 
in  uterine  fibroids,  45 
Erysipelas  of  vulva,  504 
Erythema  of  vulva,  503 
Esthiomene,  518 

Etiology  of  chronic  metritis,  602 
of  dysmenorrhoea,  421 
of  dyspareunia,  448. 
of  pelvic  cellulitis,  706 
hfematocele,  738 
hematoma,  765 
peritonitis,  690 
of  periuterine  inflammation,  677 
of  sterility,  467 
of  subinvolution  of  uterus,  649 
of  vagina,  609 
Examination,  bimanual,  298 
digital  in  dorsal  position,  298 
in  erect  position,  316 
in  genu-pectoral  position,  316 
in  left  lateral  position,  310,  315 
in  Sims's  position,  310 
dorsal  position  in,  297 
in  diagnosis,  296 
in  sterility,  466 
of  abdomen,  306 
of  rectum,  318 
rectal,  301 

recto-abdominal,  301 
specular,  304,  313 
vaginal,  method  of,  298 
vesico-rectal,  302 
Examining-tables,  294 
Excision  of  cervix  for  cancer,  62 
Exercise,  importance  of,  620 
Exploration,  rectal,  29 
External  genitals,  anatomy  of,  96 

OS,  133 
Extra-uterine  pregnancy,  cause  of  hsema- 
tocele, 746 
dangers  from  electrical  current  in,  406 
distinguished  from  hsematocele,   759, 

763 
electricity  in,  405,  406 
operations  for,  28 
Exudation  in  pelvic  cellulitis,  715 


lyphx  m  voLi'Mi'.  I. 


7H1 


Falliipian  tiilies,  aiiatnmy  nf,  |(il 
catarrh  ol",  Itl.'J 
(k'vi'li>|>iiR'iit  of,  S7 
hoiimrrliai^'i'  from,  CA'l,  746 
inall'iirmalions  of  'J.'iT 
iiMU'oiis  iiioinliraiie  of,  Itil 
porinealtility  l>y  lluids,  582 
liy  prolie,  I52 
Fiiradi/.ation,  tfoiK-ral.  ."Wt 
Ki-riiinlaiiciii,  I'oiKlilioii.s  of,  441 
Fil>roitl  tumors  canso  liemorrlia^e,  410 
of  uterus,  t'leriric'hy  in,  .'ilJK 
uteriiK'.  removed  througli  anterior  vag- 
inal wail,  •")(! 
Fibroids  diagnosed  from  celliditis,  71S 
Irom  luematocele,  7G1,  703 
electricity  in,  (iO 
of  uterus,  enucleation  of,  44 
removed  l>v  lapamtouiy.  57 
Fii'roma  and  tiliro-myoma  of  vulva,  529 

ditl'usinu  of  vulva,  520 
Fibrous  tinnors  of  uterus,  Atlee  on,  28 
Fissure  of  vulva,  494 

of  anus,  causing  dyspareimia,  453 
Fistula,    artificial    vesico-vairinal,    liistorv 
of.  31 
in  ano,  operation  for,  55 
uretliro-vaginal,  Parvin's  operation  for, 

3S 
vesico-vaginal,  history  of,  30 
operation  for,  30,  50 
Floor,  pelvic,  anatomy  of,  222 
Follicular  vidvitis,  492 
Food,  care  in  diet,  022 

value  of,  in  pelvic  disease,  369 
Forceps,  tissue,  345 
twisting,  for  wire,  352 
vulsellum,  342,  349 
Forcible  dilatation  in  dysmenorrhcea,  433 
Formula?  for  constipation,  029 
for  pruritus  vulv:e,  51.18 
for  tonics,  626,  031 
Fonrchette,  anatomy  of,  102,  105 
Fungoid  degeneration  of  endometrium,  594 
Fungosities,  uterine,  594 
Furunculosis  vulva^,  494 

G. 

Galvanometer,  necessity  for,  387 

Gangrene  of  vulva,  496 

Gartner's  ducts,  70,  181 

Gaseous  tumor  of  vulva,  536 

Genu-pectoral  position  for  displacements, 
46,  129 

Geodes,  139 

Gestation,  incapacity  for,  461 
treatment,  472 

(iiraldez's  body,  75 

(iland,  Skene's,  of  uretlira,  71,  180,  185, 
796 
of  Bartholin.    (See  Vidvo-vaf/inal  Gland.) 
vnlvo-vaginal..  catarrh  of,  499 

Glands,  titricular,  140 


(ilycerin  and  boro-;;ly(eri<les  in  <lysmeiior- 
rhoa,  420 
to  vagina,  414 
as  a  depleting  agent,  3s() 
in  chronic  metritis,  (il5 
in  congestion  of  cervix,  502 
Gohl,  chloride  of,  action  of,  372 
GonorrJKi'a,  cause  of  enilomelriti.s,  542 
pelvic  infhimmatioii,  091 
warts  of  vulva,  53(J 
latent,  48,  091 

cause  of  sterility,  400 
Cionorrlio'al  vulvitis,  492 
Graafian  follicles,  anatomy  of,  170 

develo|)meul  of,  82 
CJravid  \iterus,  injuries  of,  55 
Gramdar  <legeneration.  like  cancer,  590 
'  Greek  gynecology,  review  of,  18 
Gutheri.s's  nniscle,  186 
'  Gymnastic  exercises,  value  of,  376 
:  Gynecological  diagnosis,  283 
i      examining-table,  294 
Society,  American,  40,  64 
Gynecology,  chairs  of  66 
j      first  American  article  on,  22 
history  of,  17 
works  on,  63,  65,  C6 

H. 

I  Hematocele  and  h;ematoma.  736 

caiLsed  liy  extra-uterine  pregnancy,  746 
distinguished  from  extra-uterine  preg- 
nancy, 759 
first  essays  on,  38 
pelvic,  735 

bloody  urine  in,  754 
boundaries  of  sac,  748 
causes,  738 
contents  of  sac,  749 
contrast  with  hrematoma,  748 
diagno.sis,  757 

from  cellulitis,  717 
from  htematouia,  761 
of  source  of  blood,  760 
difl'erential  diagnosis,  table,  763 
liistorv,  737 

mobility  of  uterus  in,  759 
pathology,  743 
symptoms,  750 
temperature  in.  750 
termination  of,  755 
tumor  in,  754 

ulceration  of  cyst-wall.  756 
peritonitis  following,  747 
periuterine,  electricity  in,  397 
Haematoma  of  ovarv.  case  of,  749 

of  vulva,  497 
.  pelvic,  764 

anatomy,  764 
causes,  765 
diagnosis.  766 
prognosis,  766 
symptoms.  766 
treatment.  767 
Hiemostaiics,  418 


782 


INDEX  TO    VOLUME  I. 


Hair,  inversion  of,  on  labia,  502 
Headache,  treatment  of,  634 
Hemorrhage  after  abortion,  treatment  of, 
419 

from  corpus  luteum,  745 

from  Fallopian  tubes,  642,  746 

from  vulva,  115 
Heredity,  importance  of,  286 
Hermaphrodism,  267 

case  of  Carl  Hohmann,  273 

spurious,  277 
Hernia,  inguinal,  482 

labial,  anterior,  482 

perineal,  487 

pudendal,  486 

uterine,  257 

vaginal,  483 

ventral,  60 
Herpes  of  vulva,  502 
History  of  gynecology,  17 

rational,  of  cases,  284 
Hohmann,  C,  the  hermaphrodite,  273 
Hook,  counter-pressure,  349 
Hot- water  douche.     (See  Dovche.) 
Hot  water,  history  of  use  of,  61 
Hottentot  apron,  267 
Houston,  valve  of,  267 
Hvdatids  of  Morgagni,  288 
Hydrocele,  488 

case  of  forming  large  cyst,  535 
Hymen,  anatomy  of,  117 

atresia  of,  262 

development  of,  92 

examination  of,  125 

forms  of,  118 

malformations  of,  262 

medico-legal  importance  of,  118 

of  negro  race,  263 

resisting.  447 
Hyoscine,  hydrobromate  of,  373 
Hyperaemia,  uterine,  599 
Hyperaesthesia  of  vulva,  caufee  of  dyspa- 

reunia,  450 
Hyperplasia,  areolar,  of  uterus,  599 

electricity  in,  404 
Hypertrophy,  uterine,  599 

of  clitoris,  447 
'  treatment,  477 
Hypospadias,  265 

treatment  of,  477 
Hysterectomy,  vaginal,  position  for,  128 
Hystero-neurosis,  50 

I. 

Ice,  use  of,  after  operations,  333 
Impregnation,  artificial,  475 
Incontinence  of  urine  after  dilatation  of 

urethra,  196 
Induration,  pelvic  treatment  of,  51 
Inflammation  of  vulvo- vaginal  gland,  500 
Inflammatory  exudations,  cause  of  dyspa- 

reunia,  451 
Inguinal  hernia,  482 
Injections,  intra-uterine,  582 
of  hot  water.     (See  Douche.) 


Injections,  parenchymatous,  616 
Injuries  and  wounds  of  vulva,  479 
Insemination,  incajaacity  for,  442 
Inspection  of  abdomen,  306 

of  vulva,  297 
Instruments,  mode  of  cleaning,  330 

operating,  340 
Intercourse,  sexual.     (See  Coitus.) 
Internal  os,  134 
Inti'a-uterine  applications,  381 
injections,  582 

counter-indications,  585 
to  prevent  dangers  of,  584 
medication,  578.    (See  also  Applications.) 
Lente  on,  39 
value  of,  377 
medicator.  Palmer's,  579 

Wylie's,  428 
scarification,  knife  for,  614 
Inversion    of    inverted    uterus,    operation 

for,  57,  62 
Inverted   uterus,  reduction  of,  by  White 

and  others,  37 
Iodine,  Churchill's  tincture  of,  564 

in  chronic  metritis,  615 
Iodized  plienol,  580 
lodo-tannin,  564 
Iron  as  a  tonic,  364 

in  chronic  metritis,  612 
Irrigation,  antiseptic,  in    operations,  330, 
331 
of  uterus,  332 


J. 

Journal  of  Obstetrics,  American,  63 

K. 

Knife,  Emmet's  ball-and-socket,  345 

for  scai'ification,  614 
Kolpo-hysterectomy,  first  case  of,  55 

Labia,  hvpertrophv  of,  obstacle  to  coitus, 
447 
inversion  of  hair  of,  502 
majora,  anatomy  of,  98 
anatomy,  gross,  of,  100 
minute,  of,  101 
minora,  anatomy  of,  101 
arteries  of,  104 
malformations  of,  266 
treatment  of  hypertrophy  of,  477 
oozing  tumor  of,  531 
Labial  hernia,  anterior,  482 
Lacerations  of  cervix,  cause  of  dyspareu- 
niu,  450 
cause  of  subinvolution,  651 
operation  for,  43 
Laparo-elytrotomy,  46,  56 
Latent  gonorrhoea,  48,  691 
Lateral  displacement  of  uterus,  148 
Left  lateral  position,  description  of,  308 
digital  examination  in,  310 


!.\j>j:.\  to  Vol.1  mi-:  i. 


r«;i 


Ja-I'I        l;itcr:il       po.-ilicin,     <ilijiTti(His 

;;(»!» 

spociiliiin  in,  iUO 
Leptotlirix  vaj^iualis,  oOO 
Levator  aiii  iiiusik-,  U'JlJ 

spasm  of,  ')1;') 
Liiiaiiu'iit,  infmiililiulo-pL'lvif,  79 
Litiameiits,  romid,  107 
of  MadtltT,  •J07 
sari'd-iiteriiH',  feci  of,  1-7 

lltlTilU",  lil.'J 

aiiaioMiy  of,  'J()7 
support  tliu  uterus,  221 
Li.Lraturea,  silk,  luoiie  of  cleaning,  330 
Lipoma  of  vulva,  53U 
Literature,  lists  of,  93,  278.     (See  note 
Jiiflrx  of  Aiit/iorx  for  other  pages. 
Local  treatment  of  uterine  disease,  37G 
Lupus,  antiseptics  in,  523 

bacilius  tulierculosis  in,  519 

of  vulva,  51S 

perforans,  521 

prominens,  521 

serpiginosus,  521 

ti'eatment  of.  523 
Lymphangitis,  adeno-,  680,  759 
Lymphatics  of  uterus,  anatomy  of,  139, 


686 


31. 

Maltormations,  hindrances  to  coitus,  446 

of  clitoris,  2()(» 

of  hymen,  262 

of  ovaries,  235 

of  uterus,  238 

of  vagina,  257 

of  vulva,  264 
Massage,  general,  632 

uterine,  53,  616 

value  of,  375 
Masturliation,  diagnosis  of,  478 
^Melanoma  of  vulva,  536 
Memhrana  granulosa,  formation  of,  84 
Memiiranous  dysraenorrlicea,  434 
pathology,  435 
treatment,  435 
Menopause,  436 

symptoms  referred  to,  293 

treatment  of,  437 
Menorrhagia,  electricity  in,  391 

theory  of,  48 
Menstruation,  absence  of,  411 

disorders  of,  electricity  in,  388 

excessive,  415 

normal,  408  / 

theories  of,  409 

paint'nl,  419 

questioning  about,  287 

scanty,  413 

theory  of,  59 

vicarious,  415 
Mensuration  of  abdomen,  307 
Mental  disease  due  to  sexual  disease,  50 
Mercury,  action  of,  on  disease  of  sexual 

organs.  372 
Mesosalpinx,  development  of,  79 


Mesovariuin,  development  of,  77 
Metritis,  acute,  516 
chronic,  causes.  <)()2 
diagnosis,  606 
glvceriii      and       bonj-glvceride      in, 

"615 
iron  in,  1)12 
parenchynuitous,  599 
(piinine  in,  6.'i() 
.sponge  tents  in,  (il6 
stages  of,  601 
symptoms,  605 
treatment,  609 
general,  610 
special  medication,  Oil 
varieties,  604 
Metrorrhagia,  cancer  as  cause  of,  417 
curetting  in,  41.S 
fibroids  as  cause  of,  416 
treatment  of,  417 
Microscope  in  diagnosis,  327 
Mineral  waters,  value  of,  610,  627 
Mitchell's,  Weir,  treatment,  610,  633 
Mons  Veneris,  anatomy  of,  97 
Moral  treatment,  635 
Morgagni,  cohunns  of,  198 

hydatids  of,  23S 
Mucous  membrane,  uterine,  140 
of  cervix,  142 
of  the  ne\v-l)orn,  91 
of  uterus,  136,  140 
Miillerian  ducts,  development  of,  85 
Muscles,  levator  ani,  226 
of  pelvic  floor,  225 
of  perineum,  230 
Myoma  of  vulva,  529 
Myrtiform  ciruncles,  118 
Mvxoma  of  vulva,  530 


X. 

Needle-holder,  Enuuet's,  348 
Needles,  mode  of  use,  347 

varieties  of,  347 
Negro  race,  hymen  of,  263 
Nerve-sedatives,  372 
Nerve-tonics,  364,  372 
Nerves  of  clitoris,  109 

and  ve.ssels  of  perineum,  232 
of  uterus,  143.  155 

of  uterus.  140,  142,  146 

of  vagina,  124 

of  vulva,  100 
Nervousness,  treatment  of,  634 
Neuralgia  of  coccyx,  516 

ovarian,  electricity  in,  393 
Neuronui,    case    of,  causing   dvspareunia, 
452 

of  vulva,  536 
New  growths  of  vulva,  518 
Nitrate  of  silver  within  tlie  uterus,  581 
Nitric  acid  as  application,  565,  580 
Nuck,  canal  of,  158,  160,  236 

cyst  in,  488 
Nymphs?,   anatomy  of,   101.     (See   Labia 
Minora. ) 


784 


INDEX   TO    VOLUME  I. 


O. 

Obsletrie  Gazette,  65 

(Edema  of  vulva,  75,  495 

Oidium  albicans,  cause  of  pruritus,  506 

Ointments  for  intra-uterine  use,  581 

Oozing  tumor  of  labia,  531 

Operation  for  lacerated  cervix,  58 

for  perineal  rupture,  54,  55,  59,  234 

for  retroversion,  56 
Operations  during  pregnancy,  334 

plastic,  346 

preparatory  treatment,  336 

two  at  once  safe,  385 

when  to  be  done,  333 
Opium  in  pelvic  inflammation,  374 

use  of,  in  operations,  333 
Oi'gasm,  efiPect  on  uterus,  443 
Os,  contraction  of,  661 

external  os  tincse,  133 

internum,  134 
Osteoma  of  vulva,  536 
Ova,  formation  of,  80 

number  of, -84 
Ovarial  tubes,  174 
Ovarian  corpuscle,  Drysdale's,  43 

disease  and  dysmenorrhoea,  419 

neuralgia,  electricity  in,  393 

tumors,  diagnosis  from  hsematocele,  758 
electricity  in,  398 
works,  writers  on,  64 
Ovaries,  absence  of,  236 

anatomy  of,  107 
gross,  169 
minute,  172 

blood-supply  of,  179 

color  of,  169 

descent  of,  78 

development  of,  76 

indications  for  removal  of,  40 

malformations  of,  236 

position  of,  167 

practical   deductions  from   anatomy  of, 
181 

prolapse  of,  53 

relations  and  attachments  of,  168 
to  the  tubes,  79 

removal  of,  Battey  on,  39,  49 

rudimentary,  237 

size  of,  in  children,  85,  169 

supernumerary,  236 
Ovariotomist,  McDowell  the  first,  24 
Ovariotomists,  early  American,  27 
Ovariotomy,  drainage  in,  45 

euncleating  the  pedicle  in,  38 

high  temperature  after,  5 1 

Lyman  on,  28 

septicaemia  following,  37 

vaoinal,  40,  50 
Thomas  on,  38 
Ovaritis,  electricity  in,  393 
Ovarv,  apoplexy  of,  745 

bulb  of,  180 

epithelium  covering,  172 

hsematoma  of,  749 

prolapse  of,  37,  181 


Ovary,  prolapse  of,  in  dyspareunia,  451 
Oviducts.     (See  Fallopian  Tuben.) 
Ovula  Nabothii,  143 
Ovule,  non-maturation  of,  459 

obstruction  to  passage  of,  461 
Ovulation,  incapacity  for,  458 
Ovum,  anatomy  of,  177 

primordial,  84 

P. 

Pachydermia  of  vulva,  524 

Pachysalpingitis,  167 

Packing  the  vagina,  53 

Pain  as  symptom  of  uterine  disease,  259 

Palpation  of  abdomen,  307 

Papilliform  plexus,  180 

hemorrhage  from,  745 
Papilloma  of  vulva,  530 
Paradidymis,  76 
Parametritis  (see  Cellulitis),  705 
Parenchymatous  metritis,  chronic,  599 
Parotitis  following  operations  on  genitals, 

58 
Parovarian  cyst,  cause  of,  75 
Parovarium,  75,  180 

Pathology  of   endometritis,    chronic  cer- 
vical, 550 
chronic  corporeal,  569 
of  membranous  dysmenorrhea,  435 
of  pelvic  cellulitis,  708 
hsematocele,  743 
peritonitis,  689 
of  subinvolution  of  vagina,  668 
Pedicle,  enucleating  the,  38 
Pediculosis  pubis,  505 
Pelvic  abscess.     (See  Abscess.) 
chronic,  56,  60 
cellulitis,  electricity  in,  404 
pus  in,  710 
exudation  in,  715 
connective  tissue,  anatomy  of,  215 
disease,  jDhysical  signs  of,  293 
effusions,  Brickell  on,  49 
floor,  anatomy  of,  222 
muscles  of,  225 
physics  of,  233 
projection  of,  234 
spasm  of  muscles  of,  511 
hfematoma,  764 
induration,  treatment  of,  51 
inflammation  caused  by  gonorrhoea,  691 

use  of  opium  in,  374 
peritoneum,  anatomy  of,  204,  682 
peritonitis,  687 

complicating  dysmenorrhosa,  420 
electricity  in,  404 
hot  douche  in,  754 
sinuses  from  abscess,  732 
vessels,  enlargement  of,  156 
obstructions  in,  155 
Pencils,  gelatin,  563 
Perimetritis  (see  Peritonitis,  Pelvic),  687 
Perineal  body,  anatomy  of,  228 
function  of,  233 
hernia,  487 


lM>hX    TO    VOU'Mh'   f. 


7X5 


I'l  riiual  niptiiro,  (i[)er:iti(>ii  for,  ;")1,  55,  59, 

•J.iJ 
IVriiR'i)ri'li;i|iliy,  .)i'iiks  ciii,  o'J 
IVriiieiiiii,  "Jli',) 

failmo  ill  upt-ratioiis  lor  riiptiire  i)f,  4'J 

imisi'k's  of,  'SM 

nerves  juul  vessels  of,  'J.>2 

j)rim;irv  openilioii  tor  rupture  of,  481 

rupture  of,  o|ier:itiou  for,  42,  54,  55,  59, 

2:54 
veins  of,  1015 
Peritoneum,  jielvic.  GS2 
anatomy  of,  2U4,  (5>S2 

elianges  in  prei,'nancy,  206 
folds  of;  207 
Peritonitis,  encysted  tubercular,  58 
ha'morrhanica,  741 
followinj;;  hannatocele,  747 
pelvic,  (>87 

alidoininal  section  in,  704 

cause  of,  (Jilil 

clironic  form,  GOG 

common  form  of  pelvic  inflammation, 

700 
complicatin<r  dysmenorrhfsa,  420 
diagnosed  from  iKcmatocele,  759 
diagnosis,  ()97 
electricity  in,  404 
exacerbations  in,  695 
following  operations  on  cervix,  698 
minor  forms,  698 
pathology  of,  689 
physical  signs,  696 
prognosis,  7ul 
septic  form  of,  694 
symptomatology,  693 
treatment,  702 
tumors  in,  GOG 
tubercular,  oS,  G92 
Periuterine  adenitis  and  angeioleucitis,  680 
htematocele,  electricity  in,  397 
inflammation,  675 
delinition,  G75 
diagnosis,  653 
etiology,  677 
history,  675 
Permanganate  of  potash,  365 
Pessaries,  invention  of.  G2 

in  dysmenorrha?a,  434 
Pessary,  Hodge's  invention  of,  27 
Phenol,  iodized,  580 

Phlegmon  of  broad  ligament.     (See  Cel- 
luUtis.) 
diagnosed  from  pelvic  haematocele, 
7  Go 
Phlegmonous  vulvitis,  493 
Phosphates  as  nerve-tonics,  364 
Phosphorus,  use  of,  373 
Physical  signs  of  pelvic  disease,  293 
Pityriasis  versicolor  of  vulva.  5>)4 
Placenta,  retained,  causing  subinvolution, 

653 
Plicae  palmatae,  137 
Plica  urogenitalis,  6S 
Position,  doi-sal,  297 
erect,  examination  in,  316 
Vol.  I.— ;0 


Position,  genn-pectoral,   cxiimination   in, 
315 
in  gynecological  diagnosis,  29G 
left  lateral,  examination  in,  310 
of  uierus  in  diagnosis,  3U0 
Post-partum  hemorrhage,  causing  subinvo- 
lution, G53 
Practical  deductions  on  anatomv  of  ovarie«, 
181 
of  pelvic  connective  tissue,  219 
of  pelvic  peritoneum,  213 
of  rectum,  2(t2 
(jf  urinary  organ.s,  193 
of  uterus,  147 
of  tubes,  165 
of  vagina,  125 
of  vulva,  114 
Precocity,  239 

Pregnancy,  early  diagnosis  of,  149,  151 
in  double  uterus,  252 
operations  during,  334 
treatment  of  cervix  during,  567 
tubal,  56 
Preparatory  treatment  to  operations,  336 
Primordial  ovum,  84 
Probe,  Emmet's  flexible,  315 

introduction  of,  315 
Prognosis  of  endometritis,  chronic  cervi- 
cal, 555 
chronic  corporeal,  575 
of  pelvic  cellulitis,  718 
haMiiatoma,  766 
peritonitis,  701 
of  sterility,  4G8 
Prolapse,  anificial,  of  uterus  for  diagnosis, 
325 
of  ovary,  53,  181 

Sims's  operation  for,  37 
Prurigo  of  vulva,  503 
Pruritus  of  vulva,  505 
treatment  of,  o07 
caused  by  o'Mium  albicans,  506 
Pudendal  hernia,  486 

sac,  230 
Pudendum.     (See  Vulva.) 
Pus  in  pelvic  cellulitis,  710 

Q. 

Quinine,  use  of,  373 

after  operations,  333 
in  chronic  metritis,  630 
in  menstrual  disorders,  367 

R. 

Rectal  examination,  methods  of,  301 
Simon's  method  of,  302 
exploration.  29 
by  eversion,  38 
Rectocele,  definition  of,  487 
Rectum,  anatomy  ol",  197 
gross,  198 
minute,  250 
examination  of,  318 
practical  deductions  on  anatomy  of,  202 


786 


INDEX  TO    VOLUME  I. 


Rectum,  relations  and  attachments  of,  201 
sphincter  of,  199 
symptoms,  importance  of,  291 
Remedies  acting  on  pelvic  organs,  classifi- 
cation of,  368 
Rest  as  a  therapeutic  agent,  619 
Retroflexion  as  cause  of  dvsmenorrhoea, 
423 
of  gravid  uterus,  diagnosis,  756 
Retroversion,  operation  for,  56 
Roman  gynecology,  history  of,  20 
Rosenmiiller's  organ,  75 
Round  ligaments,  cyst  of,  488,  535 

of  uterus,  157 
Rudimentary  uterus,  242 
Rupture.     (See  Hernia.) 

of  perineum,  failure  in  operation  for,  42 
operation  for,  54,  55,  59,  234 

S. 

Sarcoma  of  vulva,  537 
Scarification,  knife  for,  614 
Scissors,  Emmet's,  344 
Sclerosis,  uterine,  599 
Sebaceous  cysts  of  vulva,  535 
Sedatives,  nerve,  372 
Semen  without  spermatozoa,  453 
Senile  changes  in  vagina,  120 
Septic  wounds,  treatment  of,  332 

pelvic  peritonitis,  694 
Septicsemia  following  ovariotomy,  37 
Serpiginous  vascular  degeneration,  509 
Sexual  sense  in  women,  444 
Shield,  Sims's,  352 

for  twisting  sutures,  352 
Silk  for  sutures,  339 

ligatures,  mode  of  cleaning,  330 
Silver  nitrate  in  endocervicitis,  564 
in  endometritis,  581 

suture,  invention  of,  33 

sutures,  339 

application  of,  348 
shouldering  of,  351 
twisting  of,  351,  352 
Simon's  speculum,  341 

spoon  curette,  361,  597 
Simpson's  sound,  302 

use  of,  303 
Sims's  depressor,  311 

position,  description  of,  308,  340 

sharp  curette,  old  model,  597 

shield,  352 

speculum,  objections  to,  310 

tenaculum,  314 
Sinus,  urogenital,  69,  88,  89 
Sinuses,  pelvic,  from  abscess,  732 
Skene,  glands  of,  in  urethra,  71,  180,  185, 

796 
Skin  diseases  of  vulva,  501 
Societies,  gynecological,  66 
Solid  uterus,  242 
Sound,  best  form  of,  302 

care  in  use  of,  in  pelvic  haematocele,  753 

Simpson's,  302 

the  uterine,  302 


Sounds,  graduated,  357 
Spasm  of  muscles  of  pelvic  floor,  511 
Spear,  Buttle' s,  for  cervix,  613 
Specula,  cylindrical  and  plurivalve,  304 
Speculum,  Brewer's,  305 
Fergusson's,  305 
Hunter-Erich's,  310 
invention  of,  20-22 
Mann's,  312 
Munde's,  313 
Nott's,  306 
Simon's,  341 

Sims's,  advantages  of,  306,  311,  340 
invention  of,  31 
mode  of  use,  313,  340 
Spermatozoa,  absence  of,  in  semen,  453 
destruction  of,  in  cervix,  454 
impediments  to  jDrogress  of,  455 
mode  of  entry  into  uterus,  43 
progress  of,  445 
Sphincter  recti,  199 
of  bladder,  189 
of  urethra,  186 
third,  198 
uteri,  135 
Sponge-holder,  Sims's,  343 
Sponges,  mode  of  cleaning,  330 
Spoon,  Simon's  sharp,  361,  597 
Spurious  hermaphrodisra,  277 
Stem,  intra-uterine,  for  drainage,  AVylie's, 

429 
Stenosis  of  cervix,  dangers  of  incision  for, 
151 
uteri,  electricitv  in,  405 
Sterility,  441 

abnormal  conditions  of,  463 
caused  by  latent  gonorrhoea,  460 
diagnosis  of,  464 
examination  in,  466 
hidden  causes  of,  467 
prognosis,  468 
subjective  symptoms  of,  462 
table  of  abnormal  conditions  in,  463 
treatment,  468 
Strychnia,  value  of,  as  a  tonic,  364 
Subinvolution,  electricity  in,  393 
non-puerperal,  601 
operations  on  vagina  in,  673 
of  uterus,  599,  637 

caused  by  tumors,  652 
course  and  results,  659 
diagnosis,  655 

diagnosis  from  chronic  metritis,  659 
differentiation,  657 
etiology,  649,  653 
exciting  causes  of,  650 
histologv,  642 
history  of,  638 
local  treatment,  664 
mechanical  treatment,  666 
operative  treatment,  666 
physical  signs  656 
symptoms  of,  655 
treatment,  661 
of  vagina,  667 
cause,  669 


L\nh'.\  TO  voi.iMr:  i. 


787 


SiiliiiiVdliition  of  vagina,  pallioloj^y,  (>(iS 
ireatmi'iit,  (>7  1 

p(>st-|iarUiiu  hi-iiiorrliagu  cuiming,  653 
Sun-l.atlis,  (i-il 
Superra'taliou,  relation  of,  to  double  uterus, 

•J53 
Siiperiiivolutiou,  electricity  in,  3D'> 
Supports  of  ilie  uterus,  221,  6."j4 

of  l.la.Uler,  22.') 
Sutures,  nuiterials  for,  338,  339 

removal  of,  353 
SyuiploMis,  iniportauce  of,  288 

of  elirouic  metritis,  ()()5 

of  pelvir  ]ierit()iiitis,  ()93 

of  sterility,  subjective,  462 

of  subinvolution  of  uterus,  655 
Sypliilitic  ulceration  of  cervix,  593 

condyloma  of  vulva,  534 

warts  of  vidva,  534 
Syringe,  applicator,  581 

T. 

Table  of  abnormal  I'onditions  in  sterilitv, 
463 
of  dilll-'rential  diagnosis  of  pelvic  ba^na- 

tocele,  763 
operation,  337 
Tables,  gynecological  examining-,  294 
Tampon,  latiipwick  for,  362 

vaginal,  361 
Temperature,  Ivigb,  after  ovariotomy,  51 
Tenaculum,  Emmet's,  314 
double,  342 
Mann's,  312 
operating,  345 
self-retaining,  577 
Sims's,  314 
Tents  in  treatment  of  endometritis,  560 
laminaria,  321,  356 
mode  of  use,  323,  356 
sponge,  321,  355 
sponge  in  chronic  metritis,  616 
tupelo,  322,  356 
Therapeutics,  general  uterine,  363,  619 
Thrombus  of  the  vulva,  497 
Tissue-forceps,  345 
Tonic,  strychnia,  value  of,  364 
Tonics,  use  of,  630 

Touch,  vesico-vaginal  and  vesico-rectal,  45 
Treatment,  constitutional,  of  chronic  ute- 
rine disease,  363,  619 
moral,  635 
of  atresia  vulvtp,  478 
of  atrophy  of  uterus,  618 
of  cervix  during  pregnancy,  567 
of  chronic  metritis,  609,  610,  611 
of  constipation,  390,  627 
of  disorders  of  menopause,  437 
of  dysmenorrha?a,  425 
of  endometritis,  chronic  cervical,  555 

corporeal,  575 
of  epispadias,  477 
of  lieadache,  634 

of  hypertrophy  of  labia  minora,  477 
of  hypospadias,  477 


Treatment  of  lupus,  523 

of  mend)ranous  dysmcnorrlura,  4.35 
of  metrorrhagia,  417 
of  nervousness,  634 
of  pelvic  abscess,  727 
a<llK'si()ns,  51-  54 
amennrrhiea,  364,  413 
celliditis,  (iO 
ha'iuatoma,  767 
induration,  51 
peritonitis,  702 
of  pruritus  vulva-,  507 
of  septic  vulva,  332 

wounds,  332 
of  sterility,  468 
of  subinvolution  of  vagina,  <)71 

of  uterus,  661,  664,  666 
preparatorv  to  operations,  33(i 
Weir  Mitchell's,  (ilO,  633 
Tubal  pregnancy,  operation  in  rupture  of 

sac,  56 
Tube,  Fallopian.     (See  Fallopian  Tube.\ 
anatomy  of,  161 
anatomy  of,  minute,  164 
development  of,  87 
malformation  of,  237 
practical  deductions  from  anatomv  of, 

165 
surgical  relations  of,  167 
Tubercular  peritonitis,  58,  692 
Tubes,  ovarial,  174 
Tumor  of  labia,  oozing,  531 
Tumors,  diagnosis  from  subinvolution.  658 
in  pelvic  peritonitis,  606 
of  uterus,  causing  subinvolution,  t)52 
ovarian,  diagnosis  from  hsematocele,  758 
Twisting  forceps  for  wire,  352 

u. 

Ulceration  of  cervix,  587 
syphilitic,  593 
of  vulva,  494 
Urachus,  88 

Ureter,  malfoi-mation  of,  261 
Ureters,  anatomy,  192 
catlieterization  of,  195 
surgical  relations  of,  196 
Urethra,  anatomy  of,  183 
gross,  185 
minute,  186 
button-hole  of,  54 
Skene's  glands  of,  70 
sphincter  muscle  of,  186 
vesical  opening  of,  187 
Urethral  caruncles  as  a  cause  of  dyspareu- 

nia,  451 
Urethrovaginal    fistula,    Parvin's   opera- 
tion, 38 
Urinary  organs,  anatomv  of,  183 

practical  deductions  from  anatomv  of, 
in  pregnancy,  193 
Urogenital  sinus,  69,  88,  89 
Uterine  appendages,  161 

disease    of,   complicating    dysmenor- 
rhea, 420 


788 


INDEX  TO    VOLUME  I. 


Uterine  decidua,  140 
depletion,  value  of,  379 
disease,  pain  as  a  symptom  of,  259 
displacements,  electricity  in,  390 
fibroids    removed  through  anterior  va- 
ginal wall,  56 
fungosities,  594 
hyperaemia,  599 
hypertrophy,  599 
massage,  53,  616 
sclerosis,  599 
sound,  302 
subinvolution,  599 
therapeutics,  363,  619 
Uterus,  abnormal  communication,  257 
anatomy,  gross,  134 

minute,  137 
anteflexion  as  malformation,  256 
arcuatus  acordiformis,  247 
arrest  of  development  of,  early,  240 

later,  254 
artificial  prolapse  for  diagnosis,  325 
atresia  of,  253 
atrophy  of,  599 
attachment'  to  vagina,  150 
bicornis  acollis,  244 
bipartitus,  243 

bleeding  from  external  coat,  153 
cavity  of,  134 
development  of,  87 
didelphys,  245 
dimensions,  132,  152 
double,  in  pregnancy,  252 

relation  to  superfostation,  353 
duplex  separatus,  244 
excessive  development  of,  239 
fcetalis  or  infantilis,  254 
gravid,  injuries  of,  55 
hernia  of,  257 

hyperplasia  of,  electricity  in,  404 
incudiformis,  255 
lymphatics  of,  139,  686 
malformations  of,  238 

in  development,  256 
massage  53,  616 
mobility,  147 

in  pelvic  hsematocele,  759 

of  mucous  membrane  of,  136,  140 
of  cervix,  142 
nerves  of,  140,  142,  146 
obliquity  of,  256 
OS  internum,  construction  of,  152 
parts  of,  133 

parvicollis  and  acollis,  256 
position,  131 

as  regards  symptoms,  351 

in  diagnosis,  300 
practical  deductions  from  anatomy  of, 
147 
in  pregnancy,  193 
pubescens,  255 

relations  to  surrounding  parts,  147 
round  ligament  of,  157 
rudimentary,  242 
septus,  248 
softening  of  tissues,  151 


solid,  242 
sphincter  of,  135 
stenosis,  electricity  in,  405 
subinvolution  of,  637 
subseptus,  249 
unifolis,  250 
supports  of,  221,  534 
ulceration  of  cervix,  154 
unicoUis,  246 

vaginal  extirpation  of,  156 
vessels  and  nerves,  143,  155 
Utricular  glands,  140 

V. 

Vagina,  arteries  and  veins  of,  122 

atresia  of,  257 

as  obsti'uction  to  coitus,  458 

blind  canals  of,  260 

development  of,  87,  92 

double,  259 

faulty  communications,  260 

malformations  of,  257 

nerves  of,  124 

operations  on,  in  subinvolution,  673 

packing  the,  53 

practical  deductions  from  anatomy  of, 
125 

relations  of,  124,  128 

senile  changes  in,  120 

shortness  as  cause  of  dyspareunia,  450 

stenosis  as  cause  of  dyspareunia,  449 

subinvolution  of,  667 

veins  of,  105 

walls  of,  119 
Vaginal  discharge  as  symptom,  292 

examination,  method  of,  298 

extirpation  of  uterus,  156 

hernia,  483 

hysterectomy,  position  for,  128 

ovariotomy,  40,  60 

tampon,  361 
Vaginismus,  511 

as  cause  of  dyspareunia,  449 

superior,  515 
Valve  of  Houston,  198 
Varicose  veins  of  vulva,  497 
Vascular  degeneration,  serpiginous,  509 
Veins,  air  in,  from  injections,  583 

of  perineum,  103 

of  vagina,  105 
Venereal  condyloma  of  vulva,  537 

warts  of  vulva,  531 
Ventral  hernia,  60 
Vesico-rectal  examination,  302 

touch,  45 
Vesico-uterine  pouch,  214 
Vesico-vaginal  fistulse,  operation  for,  30,  50 

touch,  45 
Vessels  of  the  uterus,  143 

pelvic,  enlargement  of,  156 
obstructions  in,  155 

of  vagina,  122 

and  nerves  of  perineum,  232 
of  uterus,  143,  155 
Vestibule,  anatomy  of,  110 


l.\nj:.\    TO    VOIAMF.    I. 


im 


Vi-stiWiiiiN  i>uii>s..r,  irj 

VilmiiuiiM  iinmiruliiiin,  40^ 
Vit-iritnis  monslriiarK'ii,   H') 
ViilM'lliim  I'lvrceps,  ill-,  :>J'.> 
Vulva,  alopi'i-ia  ol',  oUU,  .')Ul 
analnmy  of.  il(> 
antjc'ioiua,  ").'i(> 
utre.sia  of,  'HSl 

treatiut'iit.  178 
caiHvr,  rarcinoma,  •'):59 

epitlielionia,  •"):57 
camvr  of,  V.M 
rysts  of,  "):54 
development  of,  '.)2 
eczema,  aeiite,  503 

eh  roll  ii".  -Jl-i 
enchoiidroina,  oMt) 
erysi[)ela.s  of,  504 
erythema,  -iO^ 

tihroma  and  Jibro-niyoina  oi,  529 
lihroma  difllisuni  of,  520 
gani::reiie  ol',  49i) 
gitseoiis  tumors  of,  536 
hiematoiiia  of,  497 
heinorr]ia<re  from.  115 
herjies  of,  512 

injuries  and  wounds  of,  479 
from  coitus,  480 
labor.  480 
lipoma  of,  530 
lupus  ot",  518 
malformations  of,  204 
melanoma,  536 
myoma  of.  529 
myxoma  of,  530 
nerves  of,  100 
neuroma,  452,  536 
new  growths  of,  518 
oedema,  75,  495 
osteoma  of,  536 
papilloma  of,  530 
pediculosis  pubis  of,  505 
pityriasis  versicolor  of.  504 
pointed  condyloma  of,  531 


Vulva,  |»ra(ti<al  deduclions  from  aiialomy 
of,  114 

prurigo  of,  503 

prurltiiH  of,  505 

Harconiu,  537 

skin  disea.ses  of,  501 

syphilitic  warts  of,  534 

thrombus  of,  497 

tdceration  and  li.-ssure,  494 

varicose  veins  of,  497 

warts  of,  530,  5:51,  5:')4 
Vulvitis  as  cause  of  dyspareunia,  449 

diphtheritic,  492 

follicular,  492 

gonorrho-al,  492 

phlegmonous,  493 

simple,  490 
Vnlvo-vaginal  glands,  anatomy  ol",  116 
cysts  of,  534 

gland,  catarrh  of,  499 
inflammation  of.  500 
of  duct,  499 

w. 

Warts  of  vulva,  530,  531,  534 

vulva  caused  by  gonorrhrea,  536 
Water,  hot-,  douche.     (See  iJouche.) 

mineral,  value  of,  610 
Weir  Mitchell  treatment,  610,  633 
White  line  in  pelvis,  226 
Wolffian  bodies,  development  of,  73 

ducts,  development  of,  68 
Wounds  of  vulva,  479 

septic,  treatment  of,  332 
Woman's  lio.-^pital  of  Stale  of  New  York, 
Alumni  Association  of,  60 
foundation  of,  35 

Z. 

Zinc  as  nerve-tonic,  373  ^ 

chloride  in  endocervicitis,  565 
Zona  pellucida,  84,  177 


END    OF    VOLFME    I. 


XA4\ 
\ 


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